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DESCRIPTION OF ADHD AND MANAGEMENT
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GUIDES IN ADHDDr Hussein Abdeldayem MDHead of Ped Neurology Unit Faculty of Medicine
ADHD is the most commonly
neuro- behavioral disorder in childhood
ADHD Clinical Practice GuidelinehellipAmerican Academy of Pediatric 2011
Shifts in Conceptualizing ADHD Through the years
bull 1902 Defects in moral character bull 1934 Organically driven bull 1940 Minimal Brain Syndrome bull 1957 Hyperkinetic Impulse Disorder bull 1960 Minimal Brain Dysfunction (MBD) bull 1968 Hyperkinetic Reaction of Childhood (DSM II)
bull 1980 ADD (DSM III)
- with hyperactivity - without hyperactivity
- residual type bull 1987 ADHD (only combined symptoms) bull 1994 ADHD ndash 3 TYPES (DSM IV)
Combined Type ( 50-70) Inattentive type (~30) Hyperactive-Impulsive Type (~10)
bull
The only problem was that
they could see young children on the fields
while they studied indoors
The ears of a boy are on his back
He hears only when he is beaten
Anonymous
bull DSM-5 Future of Psychiatric Diagnosisbull Publication of the fifth edition ofbull Diagnostic and Statistical Manual of Mental
Disorders (DSM-5)bull in May 2013
No severity criteria are being recommended for this disorder at the current time
Updated May 1 2012
A 06 Attention DeficitHyperactivity Disorder
ADHD consists of a pattern of behavior that is present in multiple settings where it gives rise to social educational or work performance difficultiesA Either (A1) andor (A2)A1 InattentionA2 Hyperactivity and Impulsivity
Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that impact directly on social and academicoccupational activities
A 07 Attention DeficitHyperactivity Disorder Not Elsewhere Classified
Recommendations for severity criteria for this disorder are forthcoming
bull
bull Boys gt girls
bull Age onset gt 4 yr
ADHDDeficient Vz Disturbance
7 to 9
bull 7-9 of children and adolescents bull Adults 4 - 5 of adultsbull All levels of socioeconomicbull All levels of IQ
Estimates of worldwide prevalence of ADHD among school aged children vary from 24ndash198 Biol Psychiatry 2011
Boys gtGirls
6 1 to 12 1 to 31
ADHD in school aged childrenEducational disorder
7 years old age
onset
gt 4 y
gt2 year2010
ADHD Preschoolers
bull 1048698 Sleep problems bull 1048698 Colic
bull 1048698 Constantly in motionbull 1048698 Unresponsive to requestsbull 1048698 Trouble staying seatedbull 1048698 Demanding of attentionbull 1048698 Rapidly shift from one activity to anotherbull 1048698 Resist passive activitiesbull 1048698 Wander off alonebull 1048698 Inappropriate touchinghandling objects
SCHOOL AGE
الخارجية بالمثيرات التشتت سهولة الساكنة الحركة التعليمات إتباع على القدرة عدم الدور إنتظار على القدرة عدم المهمة إكتمال قبل السريعة االستجابة للمهمة باالنتباه اإلحتفاظ على القدرة عدم إستكمالها دون إخرى إلى مهمة من اإلنتقال
Not time specific
3ع +
األخطاء تكرار على القدرة عدم
على المحافظةالنظافة و األدوات
التعليمات اتباع عدم بكثرة التحدث
SCHOOL AGE
ADHD Adolescence and Adult
15
85
undiagnosed
Occupational impairment increased family dysfunction driving risks and SUD
ADHD in Adolescence
bull Low self-esteembull Bad interpersonal relationships bull SUDbull Delinquency
Adult ADHD
bull Family bull Workbull Friendsbull Accidentbull Addiction
Attention-Deficit Disorder Isnt Just for Kids Why Adults Are Now Being Diagnosed Too
Wall Street Journal April 2010
What is ADHD
What is ADHD EF
Impairment of Executive Function set and development التنفيذى المدير
EF
(Six aspects domains)
OrganizingPrioritizing
AndActivatingTo work
FocusingSustaining
AndShifting attention
To task
RegulatingAlertness
Sustaining effortAnd
Processing speed
1-Activation
(planning and Organizing))
2-Focus
(persisting tasks)
3-Effort
(Starting ampstopping activity)
EF(cont)
Managing frustrationAnd
Modulating emotions
Utilizing working Memory
AndAccessing recall
Monitoring And
Self-regulatingaction
4-Emotion
(managing behavior)
5-Memory
(working memory)
6-Action
(Problem solving)
Effects of ADHD on EF
1-response inhibition
2- planning
3- time responseset shifting
4- working memory
5- inner talk
6- emotional stabilitylability
7- expectation
When are ADHDimpairments Noticeable
bull some preschoolbull Some middle elementary schoolbull Some college or later
Most in 1ry school
Executive Functionschallenges may reveal Weakness bull EF weakness may not noticeable until
onersquos self-management is challenged by increased demands of adult life
EEGECG
Executive FunctionsDevelopment and Demands
bull In early childhood others perform all executive functions for the child (parents sibs and other caretakers)
bull Thereafter the child should be able (or is forced to) perform these functions for self
Onset before 7
PATHOGENESIS
summarybull structural and functional imaging studies
suggest that dysfunction of cingulate frontal and parietal cortical regions and imbalances in the dopaminergic and noradrenergic systems contribute to the pathophysiology of ADHD
Imaging Studies
1 Reduction of total brain size
2 Reduction of certain brain regions
3 Decrease blood flow in the striatum
4 Structural changes in the caudate and putamen
ADHD is a Chemical Problem
bull Dysfunction of dopaminergic and noradrenergic systems
bull Dopamine and norepinephrine are important in drugs that treat ADHD
In ADHD children the rate of glucosemetabolism in basal ganglions and in the frontal cortex is reduced
EF networks depends 1ry on 2 chemicals
Dopamine Norepinephrine
Not release and reload effectivelyMedications slow reuptake so longer in
contact with receptors
bull Methyl phenydate amp Atomoxetene
Mode of action
ndash prevents the reuptake of norepinephrine into the presynaptic neuron
X
AETIOLOGY
I AM A BUSY MOTHERor
WE ARE NOT A GOOD FAMILYor
HE IS A SPOILED BABY
1
1- Hereditary ADHD
Twin adoption
ADHD Is highly heritable
HEIGHT
ADHD
SCHIZOPHRENIA
IQ
DEPRESSION
DBH 5HTT SNAP-25
= dopamine transporter gene (DAT1)
= dopamine receptor gene (DRD)
D4
D5
= serotonin transporter gene5HTT
= others DBH HTR1Bm SNAP-25
2- Acquired Brain Injury
A prenatal Factors
CNS injury during Fetal Development
- Premature babies
-Traumainfectioncomplications
- Fetal exposure to drugs
- maternal smoking and maternal alcohol addiction
2- Acquired Brain Injury (cont)
B- CNS lesion during labour bull Type of Delivery can have impact if sudden or
extremely long and slow deliverybull Birth anoxia bull Weight at birth if SGA
C- Post Birth Factorsbull Cranial bleed bull Seizures bull Concussioncomabull Environmental chronic Lead poison
Environmental factors bull exposures to neurodevelopmental toxinstoxins
such as heavy metals and organohalide pollutants (lead mercury toxins -ldquoteratogensrdquo)
bull adverse responses to food additivesbull intolerances to foods (sugar )bull sensitivities to environmental chemicals
molds and fungi
Organochlorines and Child Development
bull Dichlorodiphenyl dichloroethylene(ppDDE) measured in umbilical cord blood
bull Serum levels were negatively associated with both mental and psychomotor development
bull The higher the serum level the worse the childs development at 13 months old
Recent studies suggest that causalpathways in some cases involve
complex interactions betweengenetic and environmental factors
2009
bull Less effective parenting - mother not in home father working more Everyone more stressed
bull Egypt educational curriculum and processbull Higher demands on childrenbull Toxins in the prenatal and early childhood environment (over
200 contaminants found in umbilical cord blood )
Why the Explosion in ADHD
MANAGEMENT
Recognition and Referral
OSHA PLAN OF MANAGEMENT
OF ADHD CHILD
Modified from AAP 2011
Recognition and Referral
Diagnosis (Assessment)
1+2+3
bull At present there is no biomedical laboratory test for ADHD
Neuropharmacology 57 (2009) 579ndash589
DD 70
DD for ADHD
bull 1- anxiety disordersbull 2- conduct disorderbull 3- oppositional defiant disorderbull 4- impulse-control or mood disordersbull 5- learning disordersbull 6- mental retardation
bull 7- gifted childrenbull 8- pervasive developmental disorders
DD for ADHD (contin)
bull 9- depression bull 10-Bipolar disorders Schizophrenia bull 11- Drugs PB CZP
bull 12- Misfits between the child and school or even the child and teacher
bull 13- substance abuse stimulants cocaine phenyclidine
bull 14- hyperthyroidismbull 15- BHL
bull
bull
Bip
ola
r D
iso
rder
Rule outs for the Diagnosis of ADHD
Myth ADHD child Can do bull Video Gamesbull Watch TVbull Computersbull Play Sportsbull Build Leggos
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
ADHD is the most commonly
neuro- behavioral disorder in childhood
ADHD Clinical Practice GuidelinehellipAmerican Academy of Pediatric 2011
Shifts in Conceptualizing ADHD Through the years
bull 1902 Defects in moral character bull 1934 Organically driven bull 1940 Minimal Brain Syndrome bull 1957 Hyperkinetic Impulse Disorder bull 1960 Minimal Brain Dysfunction (MBD) bull 1968 Hyperkinetic Reaction of Childhood (DSM II)
bull 1980 ADD (DSM III)
- with hyperactivity - without hyperactivity
- residual type bull 1987 ADHD (only combined symptoms) bull 1994 ADHD ndash 3 TYPES (DSM IV)
Combined Type ( 50-70) Inattentive type (~30) Hyperactive-Impulsive Type (~10)
bull
The only problem was that
they could see young children on the fields
while they studied indoors
The ears of a boy are on his back
He hears only when he is beaten
Anonymous
bull DSM-5 Future of Psychiatric Diagnosisbull Publication of the fifth edition ofbull Diagnostic and Statistical Manual of Mental
Disorders (DSM-5)bull in May 2013
No severity criteria are being recommended for this disorder at the current time
Updated May 1 2012
A 06 Attention DeficitHyperactivity Disorder
ADHD consists of a pattern of behavior that is present in multiple settings where it gives rise to social educational or work performance difficultiesA Either (A1) andor (A2)A1 InattentionA2 Hyperactivity and Impulsivity
Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that impact directly on social and academicoccupational activities
A 07 Attention DeficitHyperactivity Disorder Not Elsewhere Classified
Recommendations for severity criteria for this disorder are forthcoming
bull
bull Boys gt girls
bull Age onset gt 4 yr
ADHDDeficient Vz Disturbance
7 to 9
bull 7-9 of children and adolescents bull Adults 4 - 5 of adultsbull All levels of socioeconomicbull All levels of IQ
Estimates of worldwide prevalence of ADHD among school aged children vary from 24ndash198 Biol Psychiatry 2011
Boys gtGirls
6 1 to 12 1 to 31
ADHD in school aged childrenEducational disorder
7 years old age
onset
gt 4 y
gt2 year2010
ADHD Preschoolers
bull 1048698 Sleep problems bull 1048698 Colic
bull 1048698 Constantly in motionbull 1048698 Unresponsive to requestsbull 1048698 Trouble staying seatedbull 1048698 Demanding of attentionbull 1048698 Rapidly shift from one activity to anotherbull 1048698 Resist passive activitiesbull 1048698 Wander off alonebull 1048698 Inappropriate touchinghandling objects
SCHOOL AGE
الخارجية بالمثيرات التشتت سهولة الساكنة الحركة التعليمات إتباع على القدرة عدم الدور إنتظار على القدرة عدم المهمة إكتمال قبل السريعة االستجابة للمهمة باالنتباه اإلحتفاظ على القدرة عدم إستكمالها دون إخرى إلى مهمة من اإلنتقال
Not time specific
3ع +
األخطاء تكرار على القدرة عدم
على المحافظةالنظافة و األدوات
التعليمات اتباع عدم بكثرة التحدث
SCHOOL AGE
ADHD Adolescence and Adult
15
85
undiagnosed
Occupational impairment increased family dysfunction driving risks and SUD
ADHD in Adolescence
bull Low self-esteembull Bad interpersonal relationships bull SUDbull Delinquency
Adult ADHD
bull Family bull Workbull Friendsbull Accidentbull Addiction
Attention-Deficit Disorder Isnt Just for Kids Why Adults Are Now Being Diagnosed Too
Wall Street Journal April 2010
What is ADHD
What is ADHD EF
Impairment of Executive Function set and development التنفيذى المدير
EF
(Six aspects domains)
OrganizingPrioritizing
AndActivatingTo work
FocusingSustaining
AndShifting attention
To task
RegulatingAlertness
Sustaining effortAnd
Processing speed
1-Activation
(planning and Organizing))
2-Focus
(persisting tasks)
3-Effort
(Starting ampstopping activity)
EF(cont)
Managing frustrationAnd
Modulating emotions
Utilizing working Memory
AndAccessing recall
Monitoring And
Self-regulatingaction
4-Emotion
(managing behavior)
5-Memory
(working memory)
6-Action
(Problem solving)
Effects of ADHD on EF
1-response inhibition
2- planning
3- time responseset shifting
4- working memory
5- inner talk
6- emotional stabilitylability
7- expectation
When are ADHDimpairments Noticeable
bull some preschoolbull Some middle elementary schoolbull Some college or later
Most in 1ry school
Executive Functionschallenges may reveal Weakness bull EF weakness may not noticeable until
onersquos self-management is challenged by increased demands of adult life
EEGECG
Executive FunctionsDevelopment and Demands
bull In early childhood others perform all executive functions for the child (parents sibs and other caretakers)
bull Thereafter the child should be able (or is forced to) perform these functions for self
Onset before 7
PATHOGENESIS
summarybull structural and functional imaging studies
suggest that dysfunction of cingulate frontal and parietal cortical regions and imbalances in the dopaminergic and noradrenergic systems contribute to the pathophysiology of ADHD
Imaging Studies
1 Reduction of total brain size
2 Reduction of certain brain regions
3 Decrease blood flow in the striatum
4 Structural changes in the caudate and putamen
ADHD is a Chemical Problem
bull Dysfunction of dopaminergic and noradrenergic systems
bull Dopamine and norepinephrine are important in drugs that treat ADHD
In ADHD children the rate of glucosemetabolism in basal ganglions and in the frontal cortex is reduced
EF networks depends 1ry on 2 chemicals
Dopamine Norepinephrine
Not release and reload effectivelyMedications slow reuptake so longer in
contact with receptors
bull Methyl phenydate amp Atomoxetene
Mode of action
ndash prevents the reuptake of norepinephrine into the presynaptic neuron
X
AETIOLOGY
I AM A BUSY MOTHERor
WE ARE NOT A GOOD FAMILYor
HE IS A SPOILED BABY
1
1- Hereditary ADHD
Twin adoption
ADHD Is highly heritable
HEIGHT
ADHD
SCHIZOPHRENIA
IQ
DEPRESSION
DBH 5HTT SNAP-25
= dopamine transporter gene (DAT1)
= dopamine receptor gene (DRD)
D4
D5
= serotonin transporter gene5HTT
= others DBH HTR1Bm SNAP-25
2- Acquired Brain Injury
A prenatal Factors
CNS injury during Fetal Development
- Premature babies
-Traumainfectioncomplications
- Fetal exposure to drugs
- maternal smoking and maternal alcohol addiction
2- Acquired Brain Injury (cont)
B- CNS lesion during labour bull Type of Delivery can have impact if sudden or
extremely long and slow deliverybull Birth anoxia bull Weight at birth if SGA
C- Post Birth Factorsbull Cranial bleed bull Seizures bull Concussioncomabull Environmental chronic Lead poison
Environmental factors bull exposures to neurodevelopmental toxinstoxins
such as heavy metals and organohalide pollutants (lead mercury toxins -ldquoteratogensrdquo)
bull adverse responses to food additivesbull intolerances to foods (sugar )bull sensitivities to environmental chemicals
molds and fungi
Organochlorines and Child Development
bull Dichlorodiphenyl dichloroethylene(ppDDE) measured in umbilical cord blood
bull Serum levels were negatively associated with both mental and psychomotor development
bull The higher the serum level the worse the childs development at 13 months old
Recent studies suggest that causalpathways in some cases involve
complex interactions betweengenetic and environmental factors
2009
bull Less effective parenting - mother not in home father working more Everyone more stressed
bull Egypt educational curriculum and processbull Higher demands on childrenbull Toxins in the prenatal and early childhood environment (over
200 contaminants found in umbilical cord blood )
Why the Explosion in ADHD
MANAGEMENT
Recognition and Referral
OSHA PLAN OF MANAGEMENT
OF ADHD CHILD
Modified from AAP 2011
Recognition and Referral
Diagnosis (Assessment)
1+2+3
bull At present there is no biomedical laboratory test for ADHD
Neuropharmacology 57 (2009) 579ndash589
DD 70
DD for ADHD
bull 1- anxiety disordersbull 2- conduct disorderbull 3- oppositional defiant disorderbull 4- impulse-control or mood disordersbull 5- learning disordersbull 6- mental retardation
bull 7- gifted childrenbull 8- pervasive developmental disorders
DD for ADHD (contin)
bull 9- depression bull 10-Bipolar disorders Schizophrenia bull 11- Drugs PB CZP
bull 12- Misfits between the child and school or even the child and teacher
bull 13- substance abuse stimulants cocaine phenyclidine
bull 14- hyperthyroidismbull 15- BHL
bull
bull
Bip
ola
r D
iso
rder
Rule outs for the Diagnosis of ADHD
Myth ADHD child Can do bull Video Gamesbull Watch TVbull Computersbull Play Sportsbull Build Leggos
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
Shifts in Conceptualizing ADHD Through the years
bull 1902 Defects in moral character bull 1934 Organically driven bull 1940 Minimal Brain Syndrome bull 1957 Hyperkinetic Impulse Disorder bull 1960 Minimal Brain Dysfunction (MBD) bull 1968 Hyperkinetic Reaction of Childhood (DSM II)
bull 1980 ADD (DSM III)
- with hyperactivity - without hyperactivity
- residual type bull 1987 ADHD (only combined symptoms) bull 1994 ADHD ndash 3 TYPES (DSM IV)
Combined Type ( 50-70) Inattentive type (~30) Hyperactive-Impulsive Type (~10)
bull
The only problem was that
they could see young children on the fields
while they studied indoors
The ears of a boy are on his back
He hears only when he is beaten
Anonymous
bull DSM-5 Future of Psychiatric Diagnosisbull Publication of the fifth edition ofbull Diagnostic and Statistical Manual of Mental
Disorders (DSM-5)bull in May 2013
No severity criteria are being recommended for this disorder at the current time
Updated May 1 2012
A 06 Attention DeficitHyperactivity Disorder
ADHD consists of a pattern of behavior that is present in multiple settings where it gives rise to social educational or work performance difficultiesA Either (A1) andor (A2)A1 InattentionA2 Hyperactivity and Impulsivity
Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that impact directly on social and academicoccupational activities
A 07 Attention DeficitHyperactivity Disorder Not Elsewhere Classified
Recommendations for severity criteria for this disorder are forthcoming
bull
bull Boys gt girls
bull Age onset gt 4 yr
ADHDDeficient Vz Disturbance
7 to 9
bull 7-9 of children and adolescents bull Adults 4 - 5 of adultsbull All levels of socioeconomicbull All levels of IQ
Estimates of worldwide prevalence of ADHD among school aged children vary from 24ndash198 Biol Psychiatry 2011
Boys gtGirls
6 1 to 12 1 to 31
ADHD in school aged childrenEducational disorder
7 years old age
onset
gt 4 y
gt2 year2010
ADHD Preschoolers
bull 1048698 Sleep problems bull 1048698 Colic
bull 1048698 Constantly in motionbull 1048698 Unresponsive to requestsbull 1048698 Trouble staying seatedbull 1048698 Demanding of attentionbull 1048698 Rapidly shift from one activity to anotherbull 1048698 Resist passive activitiesbull 1048698 Wander off alonebull 1048698 Inappropriate touchinghandling objects
SCHOOL AGE
الخارجية بالمثيرات التشتت سهولة الساكنة الحركة التعليمات إتباع على القدرة عدم الدور إنتظار على القدرة عدم المهمة إكتمال قبل السريعة االستجابة للمهمة باالنتباه اإلحتفاظ على القدرة عدم إستكمالها دون إخرى إلى مهمة من اإلنتقال
Not time specific
3ع +
األخطاء تكرار على القدرة عدم
على المحافظةالنظافة و األدوات
التعليمات اتباع عدم بكثرة التحدث
SCHOOL AGE
ADHD Adolescence and Adult
15
85
undiagnosed
Occupational impairment increased family dysfunction driving risks and SUD
ADHD in Adolescence
bull Low self-esteembull Bad interpersonal relationships bull SUDbull Delinquency
Adult ADHD
bull Family bull Workbull Friendsbull Accidentbull Addiction
Attention-Deficit Disorder Isnt Just for Kids Why Adults Are Now Being Diagnosed Too
Wall Street Journal April 2010
What is ADHD
What is ADHD EF
Impairment of Executive Function set and development التنفيذى المدير
EF
(Six aspects domains)
OrganizingPrioritizing
AndActivatingTo work
FocusingSustaining
AndShifting attention
To task
RegulatingAlertness
Sustaining effortAnd
Processing speed
1-Activation
(planning and Organizing))
2-Focus
(persisting tasks)
3-Effort
(Starting ampstopping activity)
EF(cont)
Managing frustrationAnd
Modulating emotions
Utilizing working Memory
AndAccessing recall
Monitoring And
Self-regulatingaction
4-Emotion
(managing behavior)
5-Memory
(working memory)
6-Action
(Problem solving)
Effects of ADHD on EF
1-response inhibition
2- planning
3- time responseset shifting
4- working memory
5- inner talk
6- emotional stabilitylability
7- expectation
When are ADHDimpairments Noticeable
bull some preschoolbull Some middle elementary schoolbull Some college or later
Most in 1ry school
Executive Functionschallenges may reveal Weakness bull EF weakness may not noticeable until
onersquos self-management is challenged by increased demands of adult life
EEGECG
Executive FunctionsDevelopment and Demands
bull In early childhood others perform all executive functions for the child (parents sibs and other caretakers)
bull Thereafter the child should be able (or is forced to) perform these functions for self
Onset before 7
PATHOGENESIS
summarybull structural and functional imaging studies
suggest that dysfunction of cingulate frontal and parietal cortical regions and imbalances in the dopaminergic and noradrenergic systems contribute to the pathophysiology of ADHD
Imaging Studies
1 Reduction of total brain size
2 Reduction of certain brain regions
3 Decrease blood flow in the striatum
4 Structural changes in the caudate and putamen
ADHD is a Chemical Problem
bull Dysfunction of dopaminergic and noradrenergic systems
bull Dopamine and norepinephrine are important in drugs that treat ADHD
In ADHD children the rate of glucosemetabolism in basal ganglions and in the frontal cortex is reduced
EF networks depends 1ry on 2 chemicals
Dopamine Norepinephrine
Not release and reload effectivelyMedications slow reuptake so longer in
contact with receptors
bull Methyl phenydate amp Atomoxetene
Mode of action
ndash prevents the reuptake of norepinephrine into the presynaptic neuron
X
AETIOLOGY
I AM A BUSY MOTHERor
WE ARE NOT A GOOD FAMILYor
HE IS A SPOILED BABY
1
1- Hereditary ADHD
Twin adoption
ADHD Is highly heritable
HEIGHT
ADHD
SCHIZOPHRENIA
IQ
DEPRESSION
DBH 5HTT SNAP-25
= dopamine transporter gene (DAT1)
= dopamine receptor gene (DRD)
D4
D5
= serotonin transporter gene5HTT
= others DBH HTR1Bm SNAP-25
2- Acquired Brain Injury
A prenatal Factors
CNS injury during Fetal Development
- Premature babies
-Traumainfectioncomplications
- Fetal exposure to drugs
- maternal smoking and maternal alcohol addiction
2- Acquired Brain Injury (cont)
B- CNS lesion during labour bull Type of Delivery can have impact if sudden or
extremely long and slow deliverybull Birth anoxia bull Weight at birth if SGA
C- Post Birth Factorsbull Cranial bleed bull Seizures bull Concussioncomabull Environmental chronic Lead poison
Environmental factors bull exposures to neurodevelopmental toxinstoxins
such as heavy metals and organohalide pollutants (lead mercury toxins -ldquoteratogensrdquo)
bull adverse responses to food additivesbull intolerances to foods (sugar )bull sensitivities to environmental chemicals
molds and fungi
Organochlorines and Child Development
bull Dichlorodiphenyl dichloroethylene(ppDDE) measured in umbilical cord blood
bull Serum levels were negatively associated with both mental and psychomotor development
bull The higher the serum level the worse the childs development at 13 months old
Recent studies suggest that causalpathways in some cases involve
complex interactions betweengenetic and environmental factors
2009
bull Less effective parenting - mother not in home father working more Everyone more stressed
bull Egypt educational curriculum and processbull Higher demands on childrenbull Toxins in the prenatal and early childhood environment (over
200 contaminants found in umbilical cord blood )
Why the Explosion in ADHD
MANAGEMENT
Recognition and Referral
OSHA PLAN OF MANAGEMENT
OF ADHD CHILD
Modified from AAP 2011
Recognition and Referral
Diagnosis (Assessment)
1+2+3
bull At present there is no biomedical laboratory test for ADHD
Neuropharmacology 57 (2009) 579ndash589
DD 70
DD for ADHD
bull 1- anxiety disordersbull 2- conduct disorderbull 3- oppositional defiant disorderbull 4- impulse-control or mood disordersbull 5- learning disordersbull 6- mental retardation
bull 7- gifted childrenbull 8- pervasive developmental disorders
DD for ADHD (contin)
bull 9- depression bull 10-Bipolar disorders Schizophrenia bull 11- Drugs PB CZP
bull 12- Misfits between the child and school or even the child and teacher
bull 13- substance abuse stimulants cocaine phenyclidine
bull 14- hyperthyroidismbull 15- BHL
bull
bull
Bip
ola
r D
iso
rder
Rule outs for the Diagnosis of ADHD
Myth ADHD child Can do bull Video Gamesbull Watch TVbull Computersbull Play Sportsbull Build Leggos
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
bull 1980 ADD (DSM III)
- with hyperactivity - without hyperactivity
- residual type bull 1987 ADHD (only combined symptoms) bull 1994 ADHD ndash 3 TYPES (DSM IV)
Combined Type ( 50-70) Inattentive type (~30) Hyperactive-Impulsive Type (~10)
bull
The only problem was that
they could see young children on the fields
while they studied indoors
The ears of a boy are on his back
He hears only when he is beaten
Anonymous
bull DSM-5 Future of Psychiatric Diagnosisbull Publication of the fifth edition ofbull Diagnostic and Statistical Manual of Mental
Disorders (DSM-5)bull in May 2013
No severity criteria are being recommended for this disorder at the current time
Updated May 1 2012
A 06 Attention DeficitHyperactivity Disorder
ADHD consists of a pattern of behavior that is present in multiple settings where it gives rise to social educational or work performance difficultiesA Either (A1) andor (A2)A1 InattentionA2 Hyperactivity and Impulsivity
Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that impact directly on social and academicoccupational activities
A 07 Attention DeficitHyperactivity Disorder Not Elsewhere Classified
Recommendations for severity criteria for this disorder are forthcoming
bull
bull Boys gt girls
bull Age onset gt 4 yr
ADHDDeficient Vz Disturbance
7 to 9
bull 7-9 of children and adolescents bull Adults 4 - 5 of adultsbull All levels of socioeconomicbull All levels of IQ
Estimates of worldwide prevalence of ADHD among school aged children vary from 24ndash198 Biol Psychiatry 2011
Boys gtGirls
6 1 to 12 1 to 31
ADHD in school aged childrenEducational disorder
7 years old age
onset
gt 4 y
gt2 year2010
ADHD Preschoolers
bull 1048698 Sleep problems bull 1048698 Colic
bull 1048698 Constantly in motionbull 1048698 Unresponsive to requestsbull 1048698 Trouble staying seatedbull 1048698 Demanding of attentionbull 1048698 Rapidly shift from one activity to anotherbull 1048698 Resist passive activitiesbull 1048698 Wander off alonebull 1048698 Inappropriate touchinghandling objects
SCHOOL AGE
الخارجية بالمثيرات التشتت سهولة الساكنة الحركة التعليمات إتباع على القدرة عدم الدور إنتظار على القدرة عدم المهمة إكتمال قبل السريعة االستجابة للمهمة باالنتباه اإلحتفاظ على القدرة عدم إستكمالها دون إخرى إلى مهمة من اإلنتقال
Not time specific
3ع +
األخطاء تكرار على القدرة عدم
على المحافظةالنظافة و األدوات
التعليمات اتباع عدم بكثرة التحدث
SCHOOL AGE
ADHD Adolescence and Adult
15
85
undiagnosed
Occupational impairment increased family dysfunction driving risks and SUD
ADHD in Adolescence
bull Low self-esteembull Bad interpersonal relationships bull SUDbull Delinquency
Adult ADHD
bull Family bull Workbull Friendsbull Accidentbull Addiction
Attention-Deficit Disorder Isnt Just for Kids Why Adults Are Now Being Diagnosed Too
Wall Street Journal April 2010
What is ADHD
What is ADHD EF
Impairment of Executive Function set and development التنفيذى المدير
EF
(Six aspects domains)
OrganizingPrioritizing
AndActivatingTo work
FocusingSustaining
AndShifting attention
To task
RegulatingAlertness
Sustaining effortAnd
Processing speed
1-Activation
(planning and Organizing))
2-Focus
(persisting tasks)
3-Effort
(Starting ampstopping activity)
EF(cont)
Managing frustrationAnd
Modulating emotions
Utilizing working Memory
AndAccessing recall
Monitoring And
Self-regulatingaction
4-Emotion
(managing behavior)
5-Memory
(working memory)
6-Action
(Problem solving)
Effects of ADHD on EF
1-response inhibition
2- planning
3- time responseset shifting
4- working memory
5- inner talk
6- emotional stabilitylability
7- expectation
When are ADHDimpairments Noticeable
bull some preschoolbull Some middle elementary schoolbull Some college or later
Most in 1ry school
Executive Functionschallenges may reveal Weakness bull EF weakness may not noticeable until
onersquos self-management is challenged by increased demands of adult life
EEGECG
Executive FunctionsDevelopment and Demands
bull In early childhood others perform all executive functions for the child (parents sibs and other caretakers)
bull Thereafter the child should be able (or is forced to) perform these functions for self
Onset before 7
PATHOGENESIS
summarybull structural and functional imaging studies
suggest that dysfunction of cingulate frontal and parietal cortical regions and imbalances in the dopaminergic and noradrenergic systems contribute to the pathophysiology of ADHD
Imaging Studies
1 Reduction of total brain size
2 Reduction of certain brain regions
3 Decrease blood flow in the striatum
4 Structural changes in the caudate and putamen
ADHD is a Chemical Problem
bull Dysfunction of dopaminergic and noradrenergic systems
bull Dopamine and norepinephrine are important in drugs that treat ADHD
In ADHD children the rate of glucosemetabolism in basal ganglions and in the frontal cortex is reduced
EF networks depends 1ry on 2 chemicals
Dopamine Norepinephrine
Not release and reload effectivelyMedications slow reuptake so longer in
contact with receptors
bull Methyl phenydate amp Atomoxetene
Mode of action
ndash prevents the reuptake of norepinephrine into the presynaptic neuron
X
AETIOLOGY
I AM A BUSY MOTHERor
WE ARE NOT A GOOD FAMILYor
HE IS A SPOILED BABY
1
1- Hereditary ADHD
Twin adoption
ADHD Is highly heritable
HEIGHT
ADHD
SCHIZOPHRENIA
IQ
DEPRESSION
DBH 5HTT SNAP-25
= dopamine transporter gene (DAT1)
= dopamine receptor gene (DRD)
D4
D5
= serotonin transporter gene5HTT
= others DBH HTR1Bm SNAP-25
2- Acquired Brain Injury
A prenatal Factors
CNS injury during Fetal Development
- Premature babies
-Traumainfectioncomplications
- Fetal exposure to drugs
- maternal smoking and maternal alcohol addiction
2- Acquired Brain Injury (cont)
B- CNS lesion during labour bull Type of Delivery can have impact if sudden or
extremely long and slow deliverybull Birth anoxia bull Weight at birth if SGA
C- Post Birth Factorsbull Cranial bleed bull Seizures bull Concussioncomabull Environmental chronic Lead poison
Environmental factors bull exposures to neurodevelopmental toxinstoxins
such as heavy metals and organohalide pollutants (lead mercury toxins -ldquoteratogensrdquo)
bull adverse responses to food additivesbull intolerances to foods (sugar )bull sensitivities to environmental chemicals
molds and fungi
Organochlorines and Child Development
bull Dichlorodiphenyl dichloroethylene(ppDDE) measured in umbilical cord blood
bull Serum levels were negatively associated with both mental and psychomotor development
bull The higher the serum level the worse the childs development at 13 months old
Recent studies suggest that causalpathways in some cases involve
complex interactions betweengenetic and environmental factors
2009
bull Less effective parenting - mother not in home father working more Everyone more stressed
bull Egypt educational curriculum and processbull Higher demands on childrenbull Toxins in the prenatal and early childhood environment (over
200 contaminants found in umbilical cord blood )
Why the Explosion in ADHD
MANAGEMENT
Recognition and Referral
OSHA PLAN OF MANAGEMENT
OF ADHD CHILD
Modified from AAP 2011
Recognition and Referral
Diagnosis (Assessment)
1+2+3
bull At present there is no biomedical laboratory test for ADHD
Neuropharmacology 57 (2009) 579ndash589
DD 70
DD for ADHD
bull 1- anxiety disordersbull 2- conduct disorderbull 3- oppositional defiant disorderbull 4- impulse-control or mood disordersbull 5- learning disordersbull 6- mental retardation
bull 7- gifted childrenbull 8- pervasive developmental disorders
DD for ADHD (contin)
bull 9- depression bull 10-Bipolar disorders Schizophrenia bull 11- Drugs PB CZP
bull 12- Misfits between the child and school or even the child and teacher
bull 13- substance abuse stimulants cocaine phenyclidine
bull 14- hyperthyroidismbull 15- BHL
bull
bull
Bip
ola
r D
iso
rder
Rule outs for the Diagnosis of ADHD
Myth ADHD child Can do bull Video Gamesbull Watch TVbull Computersbull Play Sportsbull Build Leggos
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
The only problem was that
they could see young children on the fields
while they studied indoors
The ears of a boy are on his back
He hears only when he is beaten
Anonymous
bull DSM-5 Future of Psychiatric Diagnosisbull Publication of the fifth edition ofbull Diagnostic and Statistical Manual of Mental
Disorders (DSM-5)bull in May 2013
No severity criteria are being recommended for this disorder at the current time
Updated May 1 2012
A 06 Attention DeficitHyperactivity Disorder
ADHD consists of a pattern of behavior that is present in multiple settings where it gives rise to social educational or work performance difficultiesA Either (A1) andor (A2)A1 InattentionA2 Hyperactivity and Impulsivity
Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that impact directly on social and academicoccupational activities
A 07 Attention DeficitHyperactivity Disorder Not Elsewhere Classified
Recommendations for severity criteria for this disorder are forthcoming
bull
bull Boys gt girls
bull Age onset gt 4 yr
ADHDDeficient Vz Disturbance
7 to 9
bull 7-9 of children and adolescents bull Adults 4 - 5 of adultsbull All levels of socioeconomicbull All levels of IQ
Estimates of worldwide prevalence of ADHD among school aged children vary from 24ndash198 Biol Psychiatry 2011
Boys gtGirls
6 1 to 12 1 to 31
ADHD in school aged childrenEducational disorder
7 years old age
onset
gt 4 y
gt2 year2010
ADHD Preschoolers
bull 1048698 Sleep problems bull 1048698 Colic
bull 1048698 Constantly in motionbull 1048698 Unresponsive to requestsbull 1048698 Trouble staying seatedbull 1048698 Demanding of attentionbull 1048698 Rapidly shift from one activity to anotherbull 1048698 Resist passive activitiesbull 1048698 Wander off alonebull 1048698 Inappropriate touchinghandling objects
SCHOOL AGE
الخارجية بالمثيرات التشتت سهولة الساكنة الحركة التعليمات إتباع على القدرة عدم الدور إنتظار على القدرة عدم المهمة إكتمال قبل السريعة االستجابة للمهمة باالنتباه اإلحتفاظ على القدرة عدم إستكمالها دون إخرى إلى مهمة من اإلنتقال
Not time specific
3ع +
األخطاء تكرار على القدرة عدم
على المحافظةالنظافة و األدوات
التعليمات اتباع عدم بكثرة التحدث
SCHOOL AGE
ADHD Adolescence and Adult
15
85
undiagnosed
Occupational impairment increased family dysfunction driving risks and SUD
ADHD in Adolescence
bull Low self-esteembull Bad interpersonal relationships bull SUDbull Delinquency
Adult ADHD
bull Family bull Workbull Friendsbull Accidentbull Addiction
Attention-Deficit Disorder Isnt Just for Kids Why Adults Are Now Being Diagnosed Too
Wall Street Journal April 2010
What is ADHD
What is ADHD EF
Impairment of Executive Function set and development التنفيذى المدير
EF
(Six aspects domains)
OrganizingPrioritizing
AndActivatingTo work
FocusingSustaining
AndShifting attention
To task
RegulatingAlertness
Sustaining effortAnd
Processing speed
1-Activation
(planning and Organizing))
2-Focus
(persisting tasks)
3-Effort
(Starting ampstopping activity)
EF(cont)
Managing frustrationAnd
Modulating emotions
Utilizing working Memory
AndAccessing recall
Monitoring And
Self-regulatingaction
4-Emotion
(managing behavior)
5-Memory
(working memory)
6-Action
(Problem solving)
Effects of ADHD on EF
1-response inhibition
2- planning
3- time responseset shifting
4- working memory
5- inner talk
6- emotional stabilitylability
7- expectation
When are ADHDimpairments Noticeable
bull some preschoolbull Some middle elementary schoolbull Some college or later
Most in 1ry school
Executive Functionschallenges may reveal Weakness bull EF weakness may not noticeable until
onersquos self-management is challenged by increased demands of adult life
EEGECG
Executive FunctionsDevelopment and Demands
bull In early childhood others perform all executive functions for the child (parents sibs and other caretakers)
bull Thereafter the child should be able (or is forced to) perform these functions for self
Onset before 7
PATHOGENESIS
summarybull structural and functional imaging studies
suggest that dysfunction of cingulate frontal and parietal cortical regions and imbalances in the dopaminergic and noradrenergic systems contribute to the pathophysiology of ADHD
Imaging Studies
1 Reduction of total brain size
2 Reduction of certain brain regions
3 Decrease blood flow in the striatum
4 Structural changes in the caudate and putamen
ADHD is a Chemical Problem
bull Dysfunction of dopaminergic and noradrenergic systems
bull Dopamine and norepinephrine are important in drugs that treat ADHD
In ADHD children the rate of glucosemetabolism in basal ganglions and in the frontal cortex is reduced
EF networks depends 1ry on 2 chemicals
Dopamine Norepinephrine
Not release and reload effectivelyMedications slow reuptake so longer in
contact with receptors
bull Methyl phenydate amp Atomoxetene
Mode of action
ndash prevents the reuptake of norepinephrine into the presynaptic neuron
X
AETIOLOGY
I AM A BUSY MOTHERor
WE ARE NOT A GOOD FAMILYor
HE IS A SPOILED BABY
1
1- Hereditary ADHD
Twin adoption
ADHD Is highly heritable
HEIGHT
ADHD
SCHIZOPHRENIA
IQ
DEPRESSION
DBH 5HTT SNAP-25
= dopamine transporter gene (DAT1)
= dopamine receptor gene (DRD)
D4
D5
= serotonin transporter gene5HTT
= others DBH HTR1Bm SNAP-25
2- Acquired Brain Injury
A prenatal Factors
CNS injury during Fetal Development
- Premature babies
-Traumainfectioncomplications
- Fetal exposure to drugs
- maternal smoking and maternal alcohol addiction
2- Acquired Brain Injury (cont)
B- CNS lesion during labour bull Type of Delivery can have impact if sudden or
extremely long and slow deliverybull Birth anoxia bull Weight at birth if SGA
C- Post Birth Factorsbull Cranial bleed bull Seizures bull Concussioncomabull Environmental chronic Lead poison
Environmental factors bull exposures to neurodevelopmental toxinstoxins
such as heavy metals and organohalide pollutants (lead mercury toxins -ldquoteratogensrdquo)
bull adverse responses to food additivesbull intolerances to foods (sugar )bull sensitivities to environmental chemicals
molds and fungi
Organochlorines and Child Development
bull Dichlorodiphenyl dichloroethylene(ppDDE) measured in umbilical cord blood
bull Serum levels were negatively associated with both mental and psychomotor development
bull The higher the serum level the worse the childs development at 13 months old
Recent studies suggest that causalpathways in some cases involve
complex interactions betweengenetic and environmental factors
2009
bull Less effective parenting - mother not in home father working more Everyone more stressed
bull Egypt educational curriculum and processbull Higher demands on childrenbull Toxins in the prenatal and early childhood environment (over
200 contaminants found in umbilical cord blood )
Why the Explosion in ADHD
MANAGEMENT
Recognition and Referral
OSHA PLAN OF MANAGEMENT
OF ADHD CHILD
Modified from AAP 2011
Recognition and Referral
Diagnosis (Assessment)
1+2+3
bull At present there is no biomedical laboratory test for ADHD
Neuropharmacology 57 (2009) 579ndash589
DD 70
DD for ADHD
bull 1- anxiety disordersbull 2- conduct disorderbull 3- oppositional defiant disorderbull 4- impulse-control or mood disordersbull 5- learning disordersbull 6- mental retardation
bull 7- gifted childrenbull 8- pervasive developmental disorders
DD for ADHD (contin)
bull 9- depression bull 10-Bipolar disorders Schizophrenia bull 11- Drugs PB CZP
bull 12- Misfits between the child and school or even the child and teacher
bull 13- substance abuse stimulants cocaine phenyclidine
bull 14- hyperthyroidismbull 15- BHL
bull
bull
Bip
ola
r D
iso
rder
Rule outs for the Diagnosis of ADHD
Myth ADHD child Can do bull Video Gamesbull Watch TVbull Computersbull Play Sportsbull Build Leggos
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
bull DSM-5 Future of Psychiatric Diagnosisbull Publication of the fifth edition ofbull Diagnostic and Statistical Manual of Mental
Disorders (DSM-5)bull in May 2013
No severity criteria are being recommended for this disorder at the current time
Updated May 1 2012
A 06 Attention DeficitHyperactivity Disorder
ADHD consists of a pattern of behavior that is present in multiple settings where it gives rise to social educational or work performance difficultiesA Either (A1) andor (A2)A1 InattentionA2 Hyperactivity and Impulsivity
Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that impact directly on social and academicoccupational activities
A 07 Attention DeficitHyperactivity Disorder Not Elsewhere Classified
Recommendations for severity criteria for this disorder are forthcoming
bull
bull Boys gt girls
bull Age onset gt 4 yr
ADHDDeficient Vz Disturbance
7 to 9
bull 7-9 of children and adolescents bull Adults 4 - 5 of adultsbull All levels of socioeconomicbull All levels of IQ
Estimates of worldwide prevalence of ADHD among school aged children vary from 24ndash198 Biol Psychiatry 2011
Boys gtGirls
6 1 to 12 1 to 31
ADHD in school aged childrenEducational disorder
7 years old age
onset
gt 4 y
gt2 year2010
ADHD Preschoolers
bull 1048698 Sleep problems bull 1048698 Colic
bull 1048698 Constantly in motionbull 1048698 Unresponsive to requestsbull 1048698 Trouble staying seatedbull 1048698 Demanding of attentionbull 1048698 Rapidly shift from one activity to anotherbull 1048698 Resist passive activitiesbull 1048698 Wander off alonebull 1048698 Inappropriate touchinghandling objects
SCHOOL AGE
الخارجية بالمثيرات التشتت سهولة الساكنة الحركة التعليمات إتباع على القدرة عدم الدور إنتظار على القدرة عدم المهمة إكتمال قبل السريعة االستجابة للمهمة باالنتباه اإلحتفاظ على القدرة عدم إستكمالها دون إخرى إلى مهمة من اإلنتقال
Not time specific
3ع +
األخطاء تكرار على القدرة عدم
على المحافظةالنظافة و األدوات
التعليمات اتباع عدم بكثرة التحدث
SCHOOL AGE
ADHD Adolescence and Adult
15
85
undiagnosed
Occupational impairment increased family dysfunction driving risks and SUD
ADHD in Adolescence
bull Low self-esteembull Bad interpersonal relationships bull SUDbull Delinquency
Adult ADHD
bull Family bull Workbull Friendsbull Accidentbull Addiction
Attention-Deficit Disorder Isnt Just for Kids Why Adults Are Now Being Diagnosed Too
Wall Street Journal April 2010
What is ADHD
What is ADHD EF
Impairment of Executive Function set and development التنفيذى المدير
EF
(Six aspects domains)
OrganizingPrioritizing
AndActivatingTo work
FocusingSustaining
AndShifting attention
To task
RegulatingAlertness
Sustaining effortAnd
Processing speed
1-Activation
(planning and Organizing))
2-Focus
(persisting tasks)
3-Effort
(Starting ampstopping activity)
EF(cont)
Managing frustrationAnd
Modulating emotions
Utilizing working Memory
AndAccessing recall
Monitoring And
Self-regulatingaction
4-Emotion
(managing behavior)
5-Memory
(working memory)
6-Action
(Problem solving)
Effects of ADHD on EF
1-response inhibition
2- planning
3- time responseset shifting
4- working memory
5- inner talk
6- emotional stabilitylability
7- expectation
When are ADHDimpairments Noticeable
bull some preschoolbull Some middle elementary schoolbull Some college or later
Most in 1ry school
Executive Functionschallenges may reveal Weakness bull EF weakness may not noticeable until
onersquos self-management is challenged by increased demands of adult life
EEGECG
Executive FunctionsDevelopment and Demands
bull In early childhood others perform all executive functions for the child (parents sibs and other caretakers)
bull Thereafter the child should be able (or is forced to) perform these functions for self
Onset before 7
PATHOGENESIS
summarybull structural and functional imaging studies
suggest that dysfunction of cingulate frontal and parietal cortical regions and imbalances in the dopaminergic and noradrenergic systems contribute to the pathophysiology of ADHD
Imaging Studies
1 Reduction of total brain size
2 Reduction of certain brain regions
3 Decrease blood flow in the striatum
4 Structural changes in the caudate and putamen
ADHD is a Chemical Problem
bull Dysfunction of dopaminergic and noradrenergic systems
bull Dopamine and norepinephrine are important in drugs that treat ADHD
In ADHD children the rate of glucosemetabolism in basal ganglions and in the frontal cortex is reduced
EF networks depends 1ry on 2 chemicals
Dopamine Norepinephrine
Not release and reload effectivelyMedications slow reuptake so longer in
contact with receptors
bull Methyl phenydate amp Atomoxetene
Mode of action
ndash prevents the reuptake of norepinephrine into the presynaptic neuron
X
AETIOLOGY
I AM A BUSY MOTHERor
WE ARE NOT A GOOD FAMILYor
HE IS A SPOILED BABY
1
1- Hereditary ADHD
Twin adoption
ADHD Is highly heritable
HEIGHT
ADHD
SCHIZOPHRENIA
IQ
DEPRESSION
DBH 5HTT SNAP-25
= dopamine transporter gene (DAT1)
= dopamine receptor gene (DRD)
D4
D5
= serotonin transporter gene5HTT
= others DBH HTR1Bm SNAP-25
2- Acquired Brain Injury
A prenatal Factors
CNS injury during Fetal Development
- Premature babies
-Traumainfectioncomplications
- Fetal exposure to drugs
- maternal smoking and maternal alcohol addiction
2- Acquired Brain Injury (cont)
B- CNS lesion during labour bull Type of Delivery can have impact if sudden or
extremely long and slow deliverybull Birth anoxia bull Weight at birth if SGA
C- Post Birth Factorsbull Cranial bleed bull Seizures bull Concussioncomabull Environmental chronic Lead poison
Environmental factors bull exposures to neurodevelopmental toxinstoxins
such as heavy metals and organohalide pollutants (lead mercury toxins -ldquoteratogensrdquo)
bull adverse responses to food additivesbull intolerances to foods (sugar )bull sensitivities to environmental chemicals
molds and fungi
Organochlorines and Child Development
bull Dichlorodiphenyl dichloroethylene(ppDDE) measured in umbilical cord blood
bull Serum levels were negatively associated with both mental and psychomotor development
bull The higher the serum level the worse the childs development at 13 months old
Recent studies suggest that causalpathways in some cases involve
complex interactions betweengenetic and environmental factors
2009
bull Less effective parenting - mother not in home father working more Everyone more stressed
bull Egypt educational curriculum and processbull Higher demands on childrenbull Toxins in the prenatal and early childhood environment (over
200 contaminants found in umbilical cord blood )
Why the Explosion in ADHD
MANAGEMENT
Recognition and Referral
OSHA PLAN OF MANAGEMENT
OF ADHD CHILD
Modified from AAP 2011
Recognition and Referral
Diagnosis (Assessment)
1+2+3
bull At present there is no biomedical laboratory test for ADHD
Neuropharmacology 57 (2009) 579ndash589
DD 70
DD for ADHD
bull 1- anxiety disordersbull 2- conduct disorderbull 3- oppositional defiant disorderbull 4- impulse-control or mood disordersbull 5- learning disordersbull 6- mental retardation
bull 7- gifted childrenbull 8- pervasive developmental disorders
DD for ADHD (contin)
bull 9- depression bull 10-Bipolar disorders Schizophrenia bull 11- Drugs PB CZP
bull 12- Misfits between the child and school or even the child and teacher
bull 13- substance abuse stimulants cocaine phenyclidine
bull 14- hyperthyroidismbull 15- BHL
bull
bull
Bip
ola
r D
iso
rder
Rule outs for the Diagnosis of ADHD
Myth ADHD child Can do bull Video Gamesbull Watch TVbull Computersbull Play Sportsbull Build Leggos
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
No severity criteria are being recommended for this disorder at the current time
Updated May 1 2012
A 06 Attention DeficitHyperactivity Disorder
ADHD consists of a pattern of behavior that is present in multiple settings where it gives rise to social educational or work performance difficultiesA Either (A1) andor (A2)A1 InattentionA2 Hyperactivity and Impulsivity
Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that impact directly on social and academicoccupational activities
A 07 Attention DeficitHyperactivity Disorder Not Elsewhere Classified
Recommendations for severity criteria for this disorder are forthcoming
bull
bull Boys gt girls
bull Age onset gt 4 yr
ADHDDeficient Vz Disturbance
7 to 9
bull 7-9 of children and adolescents bull Adults 4 - 5 of adultsbull All levels of socioeconomicbull All levels of IQ
Estimates of worldwide prevalence of ADHD among school aged children vary from 24ndash198 Biol Psychiatry 2011
Boys gtGirls
6 1 to 12 1 to 31
ADHD in school aged childrenEducational disorder
7 years old age
onset
gt 4 y
gt2 year2010
ADHD Preschoolers
bull 1048698 Sleep problems bull 1048698 Colic
bull 1048698 Constantly in motionbull 1048698 Unresponsive to requestsbull 1048698 Trouble staying seatedbull 1048698 Demanding of attentionbull 1048698 Rapidly shift from one activity to anotherbull 1048698 Resist passive activitiesbull 1048698 Wander off alonebull 1048698 Inappropriate touchinghandling objects
SCHOOL AGE
الخارجية بالمثيرات التشتت سهولة الساكنة الحركة التعليمات إتباع على القدرة عدم الدور إنتظار على القدرة عدم المهمة إكتمال قبل السريعة االستجابة للمهمة باالنتباه اإلحتفاظ على القدرة عدم إستكمالها دون إخرى إلى مهمة من اإلنتقال
Not time specific
3ع +
األخطاء تكرار على القدرة عدم
على المحافظةالنظافة و األدوات
التعليمات اتباع عدم بكثرة التحدث
SCHOOL AGE
ADHD Adolescence and Adult
15
85
undiagnosed
Occupational impairment increased family dysfunction driving risks and SUD
ADHD in Adolescence
bull Low self-esteembull Bad interpersonal relationships bull SUDbull Delinquency
Adult ADHD
bull Family bull Workbull Friendsbull Accidentbull Addiction
Attention-Deficit Disorder Isnt Just for Kids Why Adults Are Now Being Diagnosed Too
Wall Street Journal April 2010
What is ADHD
What is ADHD EF
Impairment of Executive Function set and development التنفيذى المدير
EF
(Six aspects domains)
OrganizingPrioritizing
AndActivatingTo work
FocusingSustaining
AndShifting attention
To task
RegulatingAlertness
Sustaining effortAnd
Processing speed
1-Activation
(planning and Organizing))
2-Focus
(persisting tasks)
3-Effort
(Starting ampstopping activity)
EF(cont)
Managing frustrationAnd
Modulating emotions
Utilizing working Memory
AndAccessing recall
Monitoring And
Self-regulatingaction
4-Emotion
(managing behavior)
5-Memory
(working memory)
6-Action
(Problem solving)
Effects of ADHD on EF
1-response inhibition
2- planning
3- time responseset shifting
4- working memory
5- inner talk
6- emotional stabilitylability
7- expectation
When are ADHDimpairments Noticeable
bull some preschoolbull Some middle elementary schoolbull Some college or later
Most in 1ry school
Executive Functionschallenges may reveal Weakness bull EF weakness may not noticeable until
onersquos self-management is challenged by increased demands of adult life
EEGECG
Executive FunctionsDevelopment and Demands
bull In early childhood others perform all executive functions for the child (parents sibs and other caretakers)
bull Thereafter the child should be able (or is forced to) perform these functions for self
Onset before 7
PATHOGENESIS
summarybull structural and functional imaging studies
suggest that dysfunction of cingulate frontal and parietal cortical regions and imbalances in the dopaminergic and noradrenergic systems contribute to the pathophysiology of ADHD
Imaging Studies
1 Reduction of total brain size
2 Reduction of certain brain regions
3 Decrease blood flow in the striatum
4 Structural changes in the caudate and putamen
ADHD is a Chemical Problem
bull Dysfunction of dopaminergic and noradrenergic systems
bull Dopamine and norepinephrine are important in drugs that treat ADHD
In ADHD children the rate of glucosemetabolism in basal ganglions and in the frontal cortex is reduced
EF networks depends 1ry on 2 chemicals
Dopamine Norepinephrine
Not release and reload effectivelyMedications slow reuptake so longer in
contact with receptors
bull Methyl phenydate amp Atomoxetene
Mode of action
ndash prevents the reuptake of norepinephrine into the presynaptic neuron
X
AETIOLOGY
I AM A BUSY MOTHERor
WE ARE NOT A GOOD FAMILYor
HE IS A SPOILED BABY
1
1- Hereditary ADHD
Twin adoption
ADHD Is highly heritable
HEIGHT
ADHD
SCHIZOPHRENIA
IQ
DEPRESSION
DBH 5HTT SNAP-25
= dopamine transporter gene (DAT1)
= dopamine receptor gene (DRD)
D4
D5
= serotonin transporter gene5HTT
= others DBH HTR1Bm SNAP-25
2- Acquired Brain Injury
A prenatal Factors
CNS injury during Fetal Development
- Premature babies
-Traumainfectioncomplications
- Fetal exposure to drugs
- maternal smoking and maternal alcohol addiction
2- Acquired Brain Injury (cont)
B- CNS lesion during labour bull Type of Delivery can have impact if sudden or
extremely long and slow deliverybull Birth anoxia bull Weight at birth if SGA
C- Post Birth Factorsbull Cranial bleed bull Seizures bull Concussioncomabull Environmental chronic Lead poison
Environmental factors bull exposures to neurodevelopmental toxinstoxins
such as heavy metals and organohalide pollutants (lead mercury toxins -ldquoteratogensrdquo)
bull adverse responses to food additivesbull intolerances to foods (sugar )bull sensitivities to environmental chemicals
molds and fungi
Organochlorines and Child Development
bull Dichlorodiphenyl dichloroethylene(ppDDE) measured in umbilical cord blood
bull Serum levels were negatively associated with both mental and psychomotor development
bull The higher the serum level the worse the childs development at 13 months old
Recent studies suggest that causalpathways in some cases involve
complex interactions betweengenetic and environmental factors
2009
bull Less effective parenting - mother not in home father working more Everyone more stressed
bull Egypt educational curriculum and processbull Higher demands on childrenbull Toxins in the prenatal and early childhood environment (over
200 contaminants found in umbilical cord blood )
Why the Explosion in ADHD
MANAGEMENT
Recognition and Referral
OSHA PLAN OF MANAGEMENT
OF ADHD CHILD
Modified from AAP 2011
Recognition and Referral
Diagnosis (Assessment)
1+2+3
bull At present there is no biomedical laboratory test for ADHD
Neuropharmacology 57 (2009) 579ndash589
DD 70
DD for ADHD
bull 1- anxiety disordersbull 2- conduct disorderbull 3- oppositional defiant disorderbull 4- impulse-control or mood disordersbull 5- learning disordersbull 6- mental retardation
bull 7- gifted childrenbull 8- pervasive developmental disorders
DD for ADHD (contin)
bull 9- depression bull 10-Bipolar disorders Schizophrenia bull 11- Drugs PB CZP
bull 12- Misfits between the child and school or even the child and teacher
bull 13- substance abuse stimulants cocaine phenyclidine
bull 14- hyperthyroidismbull 15- BHL
bull
bull
Bip
ola
r D
iso
rder
Rule outs for the Diagnosis of ADHD
Myth ADHD child Can do bull Video Gamesbull Watch TVbull Computersbull Play Sportsbull Build Leggos
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
bull
bull Boys gt girls
bull Age onset gt 4 yr
ADHDDeficient Vz Disturbance
7 to 9
bull 7-9 of children and adolescents bull Adults 4 - 5 of adultsbull All levels of socioeconomicbull All levels of IQ
Estimates of worldwide prevalence of ADHD among school aged children vary from 24ndash198 Biol Psychiatry 2011
Boys gtGirls
6 1 to 12 1 to 31
ADHD in school aged childrenEducational disorder
7 years old age
onset
gt 4 y
gt2 year2010
ADHD Preschoolers
bull 1048698 Sleep problems bull 1048698 Colic
bull 1048698 Constantly in motionbull 1048698 Unresponsive to requestsbull 1048698 Trouble staying seatedbull 1048698 Demanding of attentionbull 1048698 Rapidly shift from one activity to anotherbull 1048698 Resist passive activitiesbull 1048698 Wander off alonebull 1048698 Inappropriate touchinghandling objects
SCHOOL AGE
الخارجية بالمثيرات التشتت سهولة الساكنة الحركة التعليمات إتباع على القدرة عدم الدور إنتظار على القدرة عدم المهمة إكتمال قبل السريعة االستجابة للمهمة باالنتباه اإلحتفاظ على القدرة عدم إستكمالها دون إخرى إلى مهمة من اإلنتقال
Not time specific
3ع +
األخطاء تكرار على القدرة عدم
على المحافظةالنظافة و األدوات
التعليمات اتباع عدم بكثرة التحدث
SCHOOL AGE
ADHD Adolescence and Adult
15
85
undiagnosed
Occupational impairment increased family dysfunction driving risks and SUD
ADHD in Adolescence
bull Low self-esteembull Bad interpersonal relationships bull SUDbull Delinquency
Adult ADHD
bull Family bull Workbull Friendsbull Accidentbull Addiction
Attention-Deficit Disorder Isnt Just for Kids Why Adults Are Now Being Diagnosed Too
Wall Street Journal April 2010
What is ADHD
What is ADHD EF
Impairment of Executive Function set and development التنفيذى المدير
EF
(Six aspects domains)
OrganizingPrioritizing
AndActivatingTo work
FocusingSustaining
AndShifting attention
To task
RegulatingAlertness
Sustaining effortAnd
Processing speed
1-Activation
(planning and Organizing))
2-Focus
(persisting tasks)
3-Effort
(Starting ampstopping activity)
EF(cont)
Managing frustrationAnd
Modulating emotions
Utilizing working Memory
AndAccessing recall
Monitoring And
Self-regulatingaction
4-Emotion
(managing behavior)
5-Memory
(working memory)
6-Action
(Problem solving)
Effects of ADHD on EF
1-response inhibition
2- planning
3- time responseset shifting
4- working memory
5- inner talk
6- emotional stabilitylability
7- expectation
When are ADHDimpairments Noticeable
bull some preschoolbull Some middle elementary schoolbull Some college or later
Most in 1ry school
Executive Functionschallenges may reveal Weakness bull EF weakness may not noticeable until
onersquos self-management is challenged by increased demands of adult life
EEGECG
Executive FunctionsDevelopment and Demands
bull In early childhood others perform all executive functions for the child (parents sibs and other caretakers)
bull Thereafter the child should be able (or is forced to) perform these functions for self
Onset before 7
PATHOGENESIS
summarybull structural and functional imaging studies
suggest that dysfunction of cingulate frontal and parietal cortical regions and imbalances in the dopaminergic and noradrenergic systems contribute to the pathophysiology of ADHD
Imaging Studies
1 Reduction of total brain size
2 Reduction of certain brain regions
3 Decrease blood flow in the striatum
4 Structural changes in the caudate and putamen
ADHD is a Chemical Problem
bull Dysfunction of dopaminergic and noradrenergic systems
bull Dopamine and norepinephrine are important in drugs that treat ADHD
In ADHD children the rate of glucosemetabolism in basal ganglions and in the frontal cortex is reduced
EF networks depends 1ry on 2 chemicals
Dopamine Norepinephrine
Not release and reload effectivelyMedications slow reuptake so longer in
contact with receptors
bull Methyl phenydate amp Atomoxetene
Mode of action
ndash prevents the reuptake of norepinephrine into the presynaptic neuron
X
AETIOLOGY
I AM A BUSY MOTHERor
WE ARE NOT A GOOD FAMILYor
HE IS A SPOILED BABY
1
1- Hereditary ADHD
Twin adoption
ADHD Is highly heritable
HEIGHT
ADHD
SCHIZOPHRENIA
IQ
DEPRESSION
DBH 5HTT SNAP-25
= dopamine transporter gene (DAT1)
= dopamine receptor gene (DRD)
D4
D5
= serotonin transporter gene5HTT
= others DBH HTR1Bm SNAP-25
2- Acquired Brain Injury
A prenatal Factors
CNS injury during Fetal Development
- Premature babies
-Traumainfectioncomplications
- Fetal exposure to drugs
- maternal smoking and maternal alcohol addiction
2- Acquired Brain Injury (cont)
B- CNS lesion during labour bull Type of Delivery can have impact if sudden or
extremely long and slow deliverybull Birth anoxia bull Weight at birth if SGA
C- Post Birth Factorsbull Cranial bleed bull Seizures bull Concussioncomabull Environmental chronic Lead poison
Environmental factors bull exposures to neurodevelopmental toxinstoxins
such as heavy metals and organohalide pollutants (lead mercury toxins -ldquoteratogensrdquo)
bull adverse responses to food additivesbull intolerances to foods (sugar )bull sensitivities to environmental chemicals
molds and fungi
Organochlorines and Child Development
bull Dichlorodiphenyl dichloroethylene(ppDDE) measured in umbilical cord blood
bull Serum levels were negatively associated with both mental and psychomotor development
bull The higher the serum level the worse the childs development at 13 months old
Recent studies suggest that causalpathways in some cases involve
complex interactions betweengenetic and environmental factors
2009
bull Less effective parenting - mother not in home father working more Everyone more stressed
bull Egypt educational curriculum and processbull Higher demands on childrenbull Toxins in the prenatal and early childhood environment (over
200 contaminants found in umbilical cord blood )
Why the Explosion in ADHD
MANAGEMENT
Recognition and Referral
OSHA PLAN OF MANAGEMENT
OF ADHD CHILD
Modified from AAP 2011
Recognition and Referral
Diagnosis (Assessment)
1+2+3
bull At present there is no biomedical laboratory test for ADHD
Neuropharmacology 57 (2009) 579ndash589
DD 70
DD for ADHD
bull 1- anxiety disordersbull 2- conduct disorderbull 3- oppositional defiant disorderbull 4- impulse-control or mood disordersbull 5- learning disordersbull 6- mental retardation
bull 7- gifted childrenbull 8- pervasive developmental disorders
DD for ADHD (contin)
bull 9- depression bull 10-Bipolar disorders Schizophrenia bull 11- Drugs PB CZP
bull 12- Misfits between the child and school or even the child and teacher
bull 13- substance abuse stimulants cocaine phenyclidine
bull 14- hyperthyroidismbull 15- BHL
bull
bull
Bip
ola
r D
iso
rder
Rule outs for the Diagnosis of ADHD
Myth ADHD child Can do bull Video Gamesbull Watch TVbull Computersbull Play Sportsbull Build Leggos
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
7 to 9
bull 7-9 of children and adolescents bull Adults 4 - 5 of adultsbull All levels of socioeconomicbull All levels of IQ
Estimates of worldwide prevalence of ADHD among school aged children vary from 24ndash198 Biol Psychiatry 2011
Boys gtGirls
6 1 to 12 1 to 31
ADHD in school aged childrenEducational disorder
7 years old age
onset
gt 4 y
gt2 year2010
ADHD Preschoolers
bull 1048698 Sleep problems bull 1048698 Colic
bull 1048698 Constantly in motionbull 1048698 Unresponsive to requestsbull 1048698 Trouble staying seatedbull 1048698 Demanding of attentionbull 1048698 Rapidly shift from one activity to anotherbull 1048698 Resist passive activitiesbull 1048698 Wander off alonebull 1048698 Inappropriate touchinghandling objects
SCHOOL AGE
الخارجية بالمثيرات التشتت سهولة الساكنة الحركة التعليمات إتباع على القدرة عدم الدور إنتظار على القدرة عدم المهمة إكتمال قبل السريعة االستجابة للمهمة باالنتباه اإلحتفاظ على القدرة عدم إستكمالها دون إخرى إلى مهمة من اإلنتقال
Not time specific
3ع +
األخطاء تكرار على القدرة عدم
على المحافظةالنظافة و األدوات
التعليمات اتباع عدم بكثرة التحدث
SCHOOL AGE
ADHD Adolescence and Adult
15
85
undiagnosed
Occupational impairment increased family dysfunction driving risks and SUD
ADHD in Adolescence
bull Low self-esteembull Bad interpersonal relationships bull SUDbull Delinquency
Adult ADHD
bull Family bull Workbull Friendsbull Accidentbull Addiction
Attention-Deficit Disorder Isnt Just for Kids Why Adults Are Now Being Diagnosed Too
Wall Street Journal April 2010
What is ADHD
What is ADHD EF
Impairment of Executive Function set and development التنفيذى المدير
EF
(Six aspects domains)
OrganizingPrioritizing
AndActivatingTo work
FocusingSustaining
AndShifting attention
To task
RegulatingAlertness
Sustaining effortAnd
Processing speed
1-Activation
(planning and Organizing))
2-Focus
(persisting tasks)
3-Effort
(Starting ampstopping activity)
EF(cont)
Managing frustrationAnd
Modulating emotions
Utilizing working Memory
AndAccessing recall
Monitoring And
Self-regulatingaction
4-Emotion
(managing behavior)
5-Memory
(working memory)
6-Action
(Problem solving)
Effects of ADHD on EF
1-response inhibition
2- planning
3- time responseset shifting
4- working memory
5- inner talk
6- emotional stabilitylability
7- expectation
When are ADHDimpairments Noticeable
bull some preschoolbull Some middle elementary schoolbull Some college or later
Most in 1ry school
Executive Functionschallenges may reveal Weakness bull EF weakness may not noticeable until
onersquos self-management is challenged by increased demands of adult life
EEGECG
Executive FunctionsDevelopment and Demands
bull In early childhood others perform all executive functions for the child (parents sibs and other caretakers)
bull Thereafter the child should be able (or is forced to) perform these functions for self
Onset before 7
PATHOGENESIS
summarybull structural and functional imaging studies
suggest that dysfunction of cingulate frontal and parietal cortical regions and imbalances in the dopaminergic and noradrenergic systems contribute to the pathophysiology of ADHD
Imaging Studies
1 Reduction of total brain size
2 Reduction of certain brain regions
3 Decrease blood flow in the striatum
4 Structural changes in the caudate and putamen
ADHD is a Chemical Problem
bull Dysfunction of dopaminergic and noradrenergic systems
bull Dopamine and norepinephrine are important in drugs that treat ADHD
In ADHD children the rate of glucosemetabolism in basal ganglions and in the frontal cortex is reduced
EF networks depends 1ry on 2 chemicals
Dopamine Norepinephrine
Not release and reload effectivelyMedications slow reuptake so longer in
contact with receptors
bull Methyl phenydate amp Atomoxetene
Mode of action
ndash prevents the reuptake of norepinephrine into the presynaptic neuron
X
AETIOLOGY
I AM A BUSY MOTHERor
WE ARE NOT A GOOD FAMILYor
HE IS A SPOILED BABY
1
1- Hereditary ADHD
Twin adoption
ADHD Is highly heritable
HEIGHT
ADHD
SCHIZOPHRENIA
IQ
DEPRESSION
DBH 5HTT SNAP-25
= dopamine transporter gene (DAT1)
= dopamine receptor gene (DRD)
D4
D5
= serotonin transporter gene5HTT
= others DBH HTR1Bm SNAP-25
2- Acquired Brain Injury
A prenatal Factors
CNS injury during Fetal Development
- Premature babies
-Traumainfectioncomplications
- Fetal exposure to drugs
- maternal smoking and maternal alcohol addiction
2- Acquired Brain Injury (cont)
B- CNS lesion during labour bull Type of Delivery can have impact if sudden or
extremely long and slow deliverybull Birth anoxia bull Weight at birth if SGA
C- Post Birth Factorsbull Cranial bleed bull Seizures bull Concussioncomabull Environmental chronic Lead poison
Environmental factors bull exposures to neurodevelopmental toxinstoxins
such as heavy metals and organohalide pollutants (lead mercury toxins -ldquoteratogensrdquo)
bull adverse responses to food additivesbull intolerances to foods (sugar )bull sensitivities to environmental chemicals
molds and fungi
Organochlorines and Child Development
bull Dichlorodiphenyl dichloroethylene(ppDDE) measured in umbilical cord blood
bull Serum levels were negatively associated with both mental and psychomotor development
bull The higher the serum level the worse the childs development at 13 months old
Recent studies suggest that causalpathways in some cases involve
complex interactions betweengenetic and environmental factors
2009
bull Less effective parenting - mother not in home father working more Everyone more stressed
bull Egypt educational curriculum and processbull Higher demands on childrenbull Toxins in the prenatal and early childhood environment (over
200 contaminants found in umbilical cord blood )
Why the Explosion in ADHD
MANAGEMENT
Recognition and Referral
OSHA PLAN OF MANAGEMENT
OF ADHD CHILD
Modified from AAP 2011
Recognition and Referral
Diagnosis (Assessment)
1+2+3
bull At present there is no biomedical laboratory test for ADHD
Neuropharmacology 57 (2009) 579ndash589
DD 70
DD for ADHD
bull 1- anxiety disordersbull 2- conduct disorderbull 3- oppositional defiant disorderbull 4- impulse-control or mood disordersbull 5- learning disordersbull 6- mental retardation
bull 7- gifted childrenbull 8- pervasive developmental disorders
DD for ADHD (contin)
bull 9- depression bull 10-Bipolar disorders Schizophrenia bull 11- Drugs PB CZP
bull 12- Misfits between the child and school or even the child and teacher
bull 13- substance abuse stimulants cocaine phenyclidine
bull 14- hyperthyroidismbull 15- BHL
bull
bull
Bip
ola
r D
iso
rder
Rule outs for the Diagnosis of ADHD
Myth ADHD child Can do bull Video Gamesbull Watch TVbull Computersbull Play Sportsbull Build Leggos
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
Boys gtGirls
6 1 to 12 1 to 31
ADHD in school aged childrenEducational disorder
7 years old age
onset
gt 4 y
gt2 year2010
ADHD Preschoolers
bull 1048698 Sleep problems bull 1048698 Colic
bull 1048698 Constantly in motionbull 1048698 Unresponsive to requestsbull 1048698 Trouble staying seatedbull 1048698 Demanding of attentionbull 1048698 Rapidly shift from one activity to anotherbull 1048698 Resist passive activitiesbull 1048698 Wander off alonebull 1048698 Inappropriate touchinghandling objects
SCHOOL AGE
الخارجية بالمثيرات التشتت سهولة الساكنة الحركة التعليمات إتباع على القدرة عدم الدور إنتظار على القدرة عدم المهمة إكتمال قبل السريعة االستجابة للمهمة باالنتباه اإلحتفاظ على القدرة عدم إستكمالها دون إخرى إلى مهمة من اإلنتقال
Not time specific
3ع +
األخطاء تكرار على القدرة عدم
على المحافظةالنظافة و األدوات
التعليمات اتباع عدم بكثرة التحدث
SCHOOL AGE
ADHD Adolescence and Adult
15
85
undiagnosed
Occupational impairment increased family dysfunction driving risks and SUD
ADHD in Adolescence
bull Low self-esteembull Bad interpersonal relationships bull SUDbull Delinquency
Adult ADHD
bull Family bull Workbull Friendsbull Accidentbull Addiction
Attention-Deficit Disorder Isnt Just for Kids Why Adults Are Now Being Diagnosed Too
Wall Street Journal April 2010
What is ADHD
What is ADHD EF
Impairment of Executive Function set and development التنفيذى المدير
EF
(Six aspects domains)
OrganizingPrioritizing
AndActivatingTo work
FocusingSustaining
AndShifting attention
To task
RegulatingAlertness
Sustaining effortAnd
Processing speed
1-Activation
(planning and Organizing))
2-Focus
(persisting tasks)
3-Effort
(Starting ampstopping activity)
EF(cont)
Managing frustrationAnd
Modulating emotions
Utilizing working Memory
AndAccessing recall
Monitoring And
Self-regulatingaction
4-Emotion
(managing behavior)
5-Memory
(working memory)
6-Action
(Problem solving)
Effects of ADHD on EF
1-response inhibition
2- planning
3- time responseset shifting
4- working memory
5- inner talk
6- emotional stabilitylability
7- expectation
When are ADHDimpairments Noticeable
bull some preschoolbull Some middle elementary schoolbull Some college or later
Most in 1ry school
Executive Functionschallenges may reveal Weakness bull EF weakness may not noticeable until
onersquos self-management is challenged by increased demands of adult life
EEGECG
Executive FunctionsDevelopment and Demands
bull In early childhood others perform all executive functions for the child (parents sibs and other caretakers)
bull Thereafter the child should be able (or is forced to) perform these functions for self
Onset before 7
PATHOGENESIS
summarybull structural and functional imaging studies
suggest that dysfunction of cingulate frontal and parietal cortical regions and imbalances in the dopaminergic and noradrenergic systems contribute to the pathophysiology of ADHD
Imaging Studies
1 Reduction of total brain size
2 Reduction of certain brain regions
3 Decrease blood flow in the striatum
4 Structural changes in the caudate and putamen
ADHD is a Chemical Problem
bull Dysfunction of dopaminergic and noradrenergic systems
bull Dopamine and norepinephrine are important in drugs that treat ADHD
In ADHD children the rate of glucosemetabolism in basal ganglions and in the frontal cortex is reduced
EF networks depends 1ry on 2 chemicals
Dopamine Norepinephrine
Not release and reload effectivelyMedications slow reuptake so longer in
contact with receptors
bull Methyl phenydate amp Atomoxetene
Mode of action
ndash prevents the reuptake of norepinephrine into the presynaptic neuron
X
AETIOLOGY
I AM A BUSY MOTHERor
WE ARE NOT A GOOD FAMILYor
HE IS A SPOILED BABY
1
1- Hereditary ADHD
Twin adoption
ADHD Is highly heritable
HEIGHT
ADHD
SCHIZOPHRENIA
IQ
DEPRESSION
DBH 5HTT SNAP-25
= dopamine transporter gene (DAT1)
= dopamine receptor gene (DRD)
D4
D5
= serotonin transporter gene5HTT
= others DBH HTR1Bm SNAP-25
2- Acquired Brain Injury
A prenatal Factors
CNS injury during Fetal Development
- Premature babies
-Traumainfectioncomplications
- Fetal exposure to drugs
- maternal smoking and maternal alcohol addiction
2- Acquired Brain Injury (cont)
B- CNS lesion during labour bull Type of Delivery can have impact if sudden or
extremely long and slow deliverybull Birth anoxia bull Weight at birth if SGA
C- Post Birth Factorsbull Cranial bleed bull Seizures bull Concussioncomabull Environmental chronic Lead poison
Environmental factors bull exposures to neurodevelopmental toxinstoxins
such as heavy metals and organohalide pollutants (lead mercury toxins -ldquoteratogensrdquo)
bull adverse responses to food additivesbull intolerances to foods (sugar )bull sensitivities to environmental chemicals
molds and fungi
Organochlorines and Child Development
bull Dichlorodiphenyl dichloroethylene(ppDDE) measured in umbilical cord blood
bull Serum levels were negatively associated with both mental and psychomotor development
bull The higher the serum level the worse the childs development at 13 months old
Recent studies suggest that causalpathways in some cases involve
complex interactions betweengenetic and environmental factors
2009
bull Less effective parenting - mother not in home father working more Everyone more stressed
bull Egypt educational curriculum and processbull Higher demands on childrenbull Toxins in the prenatal and early childhood environment (over
200 contaminants found in umbilical cord blood )
Why the Explosion in ADHD
MANAGEMENT
Recognition and Referral
OSHA PLAN OF MANAGEMENT
OF ADHD CHILD
Modified from AAP 2011
Recognition and Referral
Diagnosis (Assessment)
1+2+3
bull At present there is no biomedical laboratory test for ADHD
Neuropharmacology 57 (2009) 579ndash589
DD 70
DD for ADHD
bull 1- anxiety disordersbull 2- conduct disorderbull 3- oppositional defiant disorderbull 4- impulse-control or mood disordersbull 5- learning disordersbull 6- mental retardation
bull 7- gifted childrenbull 8- pervasive developmental disorders
DD for ADHD (contin)
bull 9- depression bull 10-Bipolar disorders Schizophrenia bull 11- Drugs PB CZP
bull 12- Misfits between the child and school or even the child and teacher
bull 13- substance abuse stimulants cocaine phenyclidine
bull 14- hyperthyroidismbull 15- BHL
bull
bull
Bip
ola
r D
iso
rder
Rule outs for the Diagnosis of ADHD
Myth ADHD child Can do bull Video Gamesbull Watch TVbull Computersbull Play Sportsbull Build Leggos
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
ADHD in school aged childrenEducational disorder
7 years old age
onset
gt 4 y
gt2 year2010
ADHD Preschoolers
bull 1048698 Sleep problems bull 1048698 Colic
bull 1048698 Constantly in motionbull 1048698 Unresponsive to requestsbull 1048698 Trouble staying seatedbull 1048698 Demanding of attentionbull 1048698 Rapidly shift from one activity to anotherbull 1048698 Resist passive activitiesbull 1048698 Wander off alonebull 1048698 Inappropriate touchinghandling objects
SCHOOL AGE
الخارجية بالمثيرات التشتت سهولة الساكنة الحركة التعليمات إتباع على القدرة عدم الدور إنتظار على القدرة عدم المهمة إكتمال قبل السريعة االستجابة للمهمة باالنتباه اإلحتفاظ على القدرة عدم إستكمالها دون إخرى إلى مهمة من اإلنتقال
Not time specific
3ع +
األخطاء تكرار على القدرة عدم
على المحافظةالنظافة و األدوات
التعليمات اتباع عدم بكثرة التحدث
SCHOOL AGE
ADHD Adolescence and Adult
15
85
undiagnosed
Occupational impairment increased family dysfunction driving risks and SUD
ADHD in Adolescence
bull Low self-esteembull Bad interpersonal relationships bull SUDbull Delinquency
Adult ADHD
bull Family bull Workbull Friendsbull Accidentbull Addiction
Attention-Deficit Disorder Isnt Just for Kids Why Adults Are Now Being Diagnosed Too
Wall Street Journal April 2010
What is ADHD
What is ADHD EF
Impairment of Executive Function set and development التنفيذى المدير
EF
(Six aspects domains)
OrganizingPrioritizing
AndActivatingTo work
FocusingSustaining
AndShifting attention
To task
RegulatingAlertness
Sustaining effortAnd
Processing speed
1-Activation
(planning and Organizing))
2-Focus
(persisting tasks)
3-Effort
(Starting ampstopping activity)
EF(cont)
Managing frustrationAnd
Modulating emotions
Utilizing working Memory
AndAccessing recall
Monitoring And
Self-regulatingaction
4-Emotion
(managing behavior)
5-Memory
(working memory)
6-Action
(Problem solving)
Effects of ADHD on EF
1-response inhibition
2- planning
3- time responseset shifting
4- working memory
5- inner talk
6- emotional stabilitylability
7- expectation
When are ADHDimpairments Noticeable
bull some preschoolbull Some middle elementary schoolbull Some college or later
Most in 1ry school
Executive Functionschallenges may reveal Weakness bull EF weakness may not noticeable until
onersquos self-management is challenged by increased demands of adult life
EEGECG
Executive FunctionsDevelopment and Demands
bull In early childhood others perform all executive functions for the child (parents sibs and other caretakers)
bull Thereafter the child should be able (or is forced to) perform these functions for self
Onset before 7
PATHOGENESIS
summarybull structural and functional imaging studies
suggest that dysfunction of cingulate frontal and parietal cortical regions and imbalances in the dopaminergic and noradrenergic systems contribute to the pathophysiology of ADHD
Imaging Studies
1 Reduction of total brain size
2 Reduction of certain brain regions
3 Decrease blood flow in the striatum
4 Structural changes in the caudate and putamen
ADHD is a Chemical Problem
bull Dysfunction of dopaminergic and noradrenergic systems
bull Dopamine and norepinephrine are important in drugs that treat ADHD
In ADHD children the rate of glucosemetabolism in basal ganglions and in the frontal cortex is reduced
EF networks depends 1ry on 2 chemicals
Dopamine Norepinephrine
Not release and reload effectivelyMedications slow reuptake so longer in
contact with receptors
bull Methyl phenydate amp Atomoxetene
Mode of action
ndash prevents the reuptake of norepinephrine into the presynaptic neuron
X
AETIOLOGY
I AM A BUSY MOTHERor
WE ARE NOT A GOOD FAMILYor
HE IS A SPOILED BABY
1
1- Hereditary ADHD
Twin adoption
ADHD Is highly heritable
HEIGHT
ADHD
SCHIZOPHRENIA
IQ
DEPRESSION
DBH 5HTT SNAP-25
= dopamine transporter gene (DAT1)
= dopamine receptor gene (DRD)
D4
D5
= serotonin transporter gene5HTT
= others DBH HTR1Bm SNAP-25
2- Acquired Brain Injury
A prenatal Factors
CNS injury during Fetal Development
- Premature babies
-Traumainfectioncomplications
- Fetal exposure to drugs
- maternal smoking and maternal alcohol addiction
2- Acquired Brain Injury (cont)
B- CNS lesion during labour bull Type of Delivery can have impact if sudden or
extremely long and slow deliverybull Birth anoxia bull Weight at birth if SGA
C- Post Birth Factorsbull Cranial bleed bull Seizures bull Concussioncomabull Environmental chronic Lead poison
Environmental factors bull exposures to neurodevelopmental toxinstoxins
such as heavy metals and organohalide pollutants (lead mercury toxins -ldquoteratogensrdquo)
bull adverse responses to food additivesbull intolerances to foods (sugar )bull sensitivities to environmental chemicals
molds and fungi
Organochlorines and Child Development
bull Dichlorodiphenyl dichloroethylene(ppDDE) measured in umbilical cord blood
bull Serum levels were negatively associated with both mental and psychomotor development
bull The higher the serum level the worse the childs development at 13 months old
Recent studies suggest that causalpathways in some cases involve
complex interactions betweengenetic and environmental factors
2009
bull Less effective parenting - mother not in home father working more Everyone more stressed
bull Egypt educational curriculum and processbull Higher demands on childrenbull Toxins in the prenatal and early childhood environment (over
200 contaminants found in umbilical cord blood )
Why the Explosion in ADHD
MANAGEMENT
Recognition and Referral
OSHA PLAN OF MANAGEMENT
OF ADHD CHILD
Modified from AAP 2011
Recognition and Referral
Diagnosis (Assessment)
1+2+3
bull At present there is no biomedical laboratory test for ADHD
Neuropharmacology 57 (2009) 579ndash589
DD 70
DD for ADHD
bull 1- anxiety disordersbull 2- conduct disorderbull 3- oppositional defiant disorderbull 4- impulse-control or mood disordersbull 5- learning disordersbull 6- mental retardation
bull 7- gifted childrenbull 8- pervasive developmental disorders
DD for ADHD (contin)
bull 9- depression bull 10-Bipolar disorders Schizophrenia bull 11- Drugs PB CZP
bull 12- Misfits between the child and school or even the child and teacher
bull 13- substance abuse stimulants cocaine phenyclidine
bull 14- hyperthyroidismbull 15- BHL
bull
bull
Bip
ola
r D
iso
rder
Rule outs for the Diagnosis of ADHD
Myth ADHD child Can do bull Video Gamesbull Watch TVbull Computersbull Play Sportsbull Build Leggos
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
onset
gt 4 y
gt2 year2010
ADHD Preschoolers
bull 1048698 Sleep problems bull 1048698 Colic
bull 1048698 Constantly in motionbull 1048698 Unresponsive to requestsbull 1048698 Trouble staying seatedbull 1048698 Demanding of attentionbull 1048698 Rapidly shift from one activity to anotherbull 1048698 Resist passive activitiesbull 1048698 Wander off alonebull 1048698 Inappropriate touchinghandling objects
SCHOOL AGE
الخارجية بالمثيرات التشتت سهولة الساكنة الحركة التعليمات إتباع على القدرة عدم الدور إنتظار على القدرة عدم المهمة إكتمال قبل السريعة االستجابة للمهمة باالنتباه اإلحتفاظ على القدرة عدم إستكمالها دون إخرى إلى مهمة من اإلنتقال
Not time specific
3ع +
األخطاء تكرار على القدرة عدم
على المحافظةالنظافة و األدوات
التعليمات اتباع عدم بكثرة التحدث
SCHOOL AGE
ADHD Adolescence and Adult
15
85
undiagnosed
Occupational impairment increased family dysfunction driving risks and SUD
ADHD in Adolescence
bull Low self-esteembull Bad interpersonal relationships bull SUDbull Delinquency
Adult ADHD
bull Family bull Workbull Friendsbull Accidentbull Addiction
Attention-Deficit Disorder Isnt Just for Kids Why Adults Are Now Being Diagnosed Too
Wall Street Journal April 2010
What is ADHD
What is ADHD EF
Impairment of Executive Function set and development التنفيذى المدير
EF
(Six aspects domains)
OrganizingPrioritizing
AndActivatingTo work
FocusingSustaining
AndShifting attention
To task
RegulatingAlertness
Sustaining effortAnd
Processing speed
1-Activation
(planning and Organizing))
2-Focus
(persisting tasks)
3-Effort
(Starting ampstopping activity)
EF(cont)
Managing frustrationAnd
Modulating emotions
Utilizing working Memory
AndAccessing recall
Monitoring And
Self-regulatingaction
4-Emotion
(managing behavior)
5-Memory
(working memory)
6-Action
(Problem solving)
Effects of ADHD on EF
1-response inhibition
2- planning
3- time responseset shifting
4- working memory
5- inner talk
6- emotional stabilitylability
7- expectation
When are ADHDimpairments Noticeable
bull some preschoolbull Some middle elementary schoolbull Some college or later
Most in 1ry school
Executive Functionschallenges may reveal Weakness bull EF weakness may not noticeable until
onersquos self-management is challenged by increased demands of adult life
EEGECG
Executive FunctionsDevelopment and Demands
bull In early childhood others perform all executive functions for the child (parents sibs and other caretakers)
bull Thereafter the child should be able (or is forced to) perform these functions for self
Onset before 7
PATHOGENESIS
summarybull structural and functional imaging studies
suggest that dysfunction of cingulate frontal and parietal cortical regions and imbalances in the dopaminergic and noradrenergic systems contribute to the pathophysiology of ADHD
Imaging Studies
1 Reduction of total brain size
2 Reduction of certain brain regions
3 Decrease blood flow in the striatum
4 Structural changes in the caudate and putamen
ADHD is a Chemical Problem
bull Dysfunction of dopaminergic and noradrenergic systems
bull Dopamine and norepinephrine are important in drugs that treat ADHD
In ADHD children the rate of glucosemetabolism in basal ganglions and in the frontal cortex is reduced
EF networks depends 1ry on 2 chemicals
Dopamine Norepinephrine
Not release and reload effectivelyMedications slow reuptake so longer in
contact with receptors
bull Methyl phenydate amp Atomoxetene
Mode of action
ndash prevents the reuptake of norepinephrine into the presynaptic neuron
X
AETIOLOGY
I AM A BUSY MOTHERor
WE ARE NOT A GOOD FAMILYor
HE IS A SPOILED BABY
1
1- Hereditary ADHD
Twin adoption
ADHD Is highly heritable
HEIGHT
ADHD
SCHIZOPHRENIA
IQ
DEPRESSION
DBH 5HTT SNAP-25
= dopamine transporter gene (DAT1)
= dopamine receptor gene (DRD)
D4
D5
= serotonin transporter gene5HTT
= others DBH HTR1Bm SNAP-25
2- Acquired Brain Injury
A prenatal Factors
CNS injury during Fetal Development
- Premature babies
-Traumainfectioncomplications
- Fetal exposure to drugs
- maternal smoking and maternal alcohol addiction
2- Acquired Brain Injury (cont)
B- CNS lesion during labour bull Type of Delivery can have impact if sudden or
extremely long and slow deliverybull Birth anoxia bull Weight at birth if SGA
C- Post Birth Factorsbull Cranial bleed bull Seizures bull Concussioncomabull Environmental chronic Lead poison
Environmental factors bull exposures to neurodevelopmental toxinstoxins
such as heavy metals and organohalide pollutants (lead mercury toxins -ldquoteratogensrdquo)
bull adverse responses to food additivesbull intolerances to foods (sugar )bull sensitivities to environmental chemicals
molds and fungi
Organochlorines and Child Development
bull Dichlorodiphenyl dichloroethylene(ppDDE) measured in umbilical cord blood
bull Serum levels were negatively associated with both mental and psychomotor development
bull The higher the serum level the worse the childs development at 13 months old
Recent studies suggest that causalpathways in some cases involve
complex interactions betweengenetic and environmental factors
2009
bull Less effective parenting - mother not in home father working more Everyone more stressed
bull Egypt educational curriculum and processbull Higher demands on childrenbull Toxins in the prenatal and early childhood environment (over
200 contaminants found in umbilical cord blood )
Why the Explosion in ADHD
MANAGEMENT
Recognition and Referral
OSHA PLAN OF MANAGEMENT
OF ADHD CHILD
Modified from AAP 2011
Recognition and Referral
Diagnosis (Assessment)
1+2+3
bull At present there is no biomedical laboratory test for ADHD
Neuropharmacology 57 (2009) 579ndash589
DD 70
DD for ADHD
bull 1- anxiety disordersbull 2- conduct disorderbull 3- oppositional defiant disorderbull 4- impulse-control or mood disordersbull 5- learning disordersbull 6- mental retardation
bull 7- gifted childrenbull 8- pervasive developmental disorders
DD for ADHD (contin)
bull 9- depression bull 10-Bipolar disorders Schizophrenia bull 11- Drugs PB CZP
bull 12- Misfits between the child and school or even the child and teacher
bull 13- substance abuse stimulants cocaine phenyclidine
bull 14- hyperthyroidismbull 15- BHL
bull
bull
Bip
ola
r D
iso
rder
Rule outs for the Diagnosis of ADHD
Myth ADHD child Can do bull Video Gamesbull Watch TVbull Computersbull Play Sportsbull Build Leggos
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
ADHD Preschoolers
bull 1048698 Sleep problems bull 1048698 Colic
bull 1048698 Constantly in motionbull 1048698 Unresponsive to requestsbull 1048698 Trouble staying seatedbull 1048698 Demanding of attentionbull 1048698 Rapidly shift from one activity to anotherbull 1048698 Resist passive activitiesbull 1048698 Wander off alonebull 1048698 Inappropriate touchinghandling objects
SCHOOL AGE
الخارجية بالمثيرات التشتت سهولة الساكنة الحركة التعليمات إتباع على القدرة عدم الدور إنتظار على القدرة عدم المهمة إكتمال قبل السريعة االستجابة للمهمة باالنتباه اإلحتفاظ على القدرة عدم إستكمالها دون إخرى إلى مهمة من اإلنتقال
Not time specific
3ع +
األخطاء تكرار على القدرة عدم
على المحافظةالنظافة و األدوات
التعليمات اتباع عدم بكثرة التحدث
SCHOOL AGE
ADHD Adolescence and Adult
15
85
undiagnosed
Occupational impairment increased family dysfunction driving risks and SUD
ADHD in Adolescence
bull Low self-esteembull Bad interpersonal relationships bull SUDbull Delinquency
Adult ADHD
bull Family bull Workbull Friendsbull Accidentbull Addiction
Attention-Deficit Disorder Isnt Just for Kids Why Adults Are Now Being Diagnosed Too
Wall Street Journal April 2010
What is ADHD
What is ADHD EF
Impairment of Executive Function set and development التنفيذى المدير
EF
(Six aspects domains)
OrganizingPrioritizing
AndActivatingTo work
FocusingSustaining
AndShifting attention
To task
RegulatingAlertness
Sustaining effortAnd
Processing speed
1-Activation
(planning and Organizing))
2-Focus
(persisting tasks)
3-Effort
(Starting ampstopping activity)
EF(cont)
Managing frustrationAnd
Modulating emotions
Utilizing working Memory
AndAccessing recall
Monitoring And
Self-regulatingaction
4-Emotion
(managing behavior)
5-Memory
(working memory)
6-Action
(Problem solving)
Effects of ADHD on EF
1-response inhibition
2- planning
3- time responseset shifting
4- working memory
5- inner talk
6- emotional stabilitylability
7- expectation
When are ADHDimpairments Noticeable
bull some preschoolbull Some middle elementary schoolbull Some college or later
Most in 1ry school
Executive Functionschallenges may reveal Weakness bull EF weakness may not noticeable until
onersquos self-management is challenged by increased demands of adult life
EEGECG
Executive FunctionsDevelopment and Demands
bull In early childhood others perform all executive functions for the child (parents sibs and other caretakers)
bull Thereafter the child should be able (or is forced to) perform these functions for self
Onset before 7
PATHOGENESIS
summarybull structural and functional imaging studies
suggest that dysfunction of cingulate frontal and parietal cortical regions and imbalances in the dopaminergic and noradrenergic systems contribute to the pathophysiology of ADHD
Imaging Studies
1 Reduction of total brain size
2 Reduction of certain brain regions
3 Decrease blood flow in the striatum
4 Structural changes in the caudate and putamen
ADHD is a Chemical Problem
bull Dysfunction of dopaminergic and noradrenergic systems
bull Dopamine and norepinephrine are important in drugs that treat ADHD
In ADHD children the rate of glucosemetabolism in basal ganglions and in the frontal cortex is reduced
EF networks depends 1ry on 2 chemicals
Dopamine Norepinephrine
Not release and reload effectivelyMedications slow reuptake so longer in
contact with receptors
bull Methyl phenydate amp Atomoxetene
Mode of action
ndash prevents the reuptake of norepinephrine into the presynaptic neuron
X
AETIOLOGY
I AM A BUSY MOTHERor
WE ARE NOT A GOOD FAMILYor
HE IS A SPOILED BABY
1
1- Hereditary ADHD
Twin adoption
ADHD Is highly heritable
HEIGHT
ADHD
SCHIZOPHRENIA
IQ
DEPRESSION
DBH 5HTT SNAP-25
= dopamine transporter gene (DAT1)
= dopamine receptor gene (DRD)
D4
D5
= serotonin transporter gene5HTT
= others DBH HTR1Bm SNAP-25
2- Acquired Brain Injury
A prenatal Factors
CNS injury during Fetal Development
- Premature babies
-Traumainfectioncomplications
- Fetal exposure to drugs
- maternal smoking and maternal alcohol addiction
2- Acquired Brain Injury (cont)
B- CNS lesion during labour bull Type of Delivery can have impact if sudden or
extremely long and slow deliverybull Birth anoxia bull Weight at birth if SGA
C- Post Birth Factorsbull Cranial bleed bull Seizures bull Concussioncomabull Environmental chronic Lead poison
Environmental factors bull exposures to neurodevelopmental toxinstoxins
such as heavy metals and organohalide pollutants (lead mercury toxins -ldquoteratogensrdquo)
bull adverse responses to food additivesbull intolerances to foods (sugar )bull sensitivities to environmental chemicals
molds and fungi
Organochlorines and Child Development
bull Dichlorodiphenyl dichloroethylene(ppDDE) measured in umbilical cord blood
bull Serum levels were negatively associated with both mental and psychomotor development
bull The higher the serum level the worse the childs development at 13 months old
Recent studies suggest that causalpathways in some cases involve
complex interactions betweengenetic and environmental factors
2009
bull Less effective parenting - mother not in home father working more Everyone more stressed
bull Egypt educational curriculum and processbull Higher demands on childrenbull Toxins in the prenatal and early childhood environment (over
200 contaminants found in umbilical cord blood )
Why the Explosion in ADHD
MANAGEMENT
Recognition and Referral
OSHA PLAN OF MANAGEMENT
OF ADHD CHILD
Modified from AAP 2011
Recognition and Referral
Diagnosis (Assessment)
1+2+3
bull At present there is no biomedical laboratory test for ADHD
Neuropharmacology 57 (2009) 579ndash589
DD 70
DD for ADHD
bull 1- anxiety disordersbull 2- conduct disorderbull 3- oppositional defiant disorderbull 4- impulse-control or mood disordersbull 5- learning disordersbull 6- mental retardation
bull 7- gifted childrenbull 8- pervasive developmental disorders
DD for ADHD (contin)
bull 9- depression bull 10-Bipolar disorders Schizophrenia bull 11- Drugs PB CZP
bull 12- Misfits between the child and school or even the child and teacher
bull 13- substance abuse stimulants cocaine phenyclidine
bull 14- hyperthyroidismbull 15- BHL
bull
bull
Bip
ola
r D
iso
rder
Rule outs for the Diagnosis of ADHD
Myth ADHD child Can do bull Video Gamesbull Watch TVbull Computersbull Play Sportsbull Build Leggos
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
SCHOOL AGE
الخارجية بالمثيرات التشتت سهولة الساكنة الحركة التعليمات إتباع على القدرة عدم الدور إنتظار على القدرة عدم المهمة إكتمال قبل السريعة االستجابة للمهمة باالنتباه اإلحتفاظ على القدرة عدم إستكمالها دون إخرى إلى مهمة من اإلنتقال
Not time specific
3ع +
األخطاء تكرار على القدرة عدم
على المحافظةالنظافة و األدوات
التعليمات اتباع عدم بكثرة التحدث
SCHOOL AGE
ADHD Adolescence and Adult
15
85
undiagnosed
Occupational impairment increased family dysfunction driving risks and SUD
ADHD in Adolescence
bull Low self-esteembull Bad interpersonal relationships bull SUDbull Delinquency
Adult ADHD
bull Family bull Workbull Friendsbull Accidentbull Addiction
Attention-Deficit Disorder Isnt Just for Kids Why Adults Are Now Being Diagnosed Too
Wall Street Journal April 2010
What is ADHD
What is ADHD EF
Impairment of Executive Function set and development التنفيذى المدير
EF
(Six aspects domains)
OrganizingPrioritizing
AndActivatingTo work
FocusingSustaining
AndShifting attention
To task
RegulatingAlertness
Sustaining effortAnd
Processing speed
1-Activation
(planning and Organizing))
2-Focus
(persisting tasks)
3-Effort
(Starting ampstopping activity)
EF(cont)
Managing frustrationAnd
Modulating emotions
Utilizing working Memory
AndAccessing recall
Monitoring And
Self-regulatingaction
4-Emotion
(managing behavior)
5-Memory
(working memory)
6-Action
(Problem solving)
Effects of ADHD on EF
1-response inhibition
2- planning
3- time responseset shifting
4- working memory
5- inner talk
6- emotional stabilitylability
7- expectation
When are ADHDimpairments Noticeable
bull some preschoolbull Some middle elementary schoolbull Some college or later
Most in 1ry school
Executive Functionschallenges may reveal Weakness bull EF weakness may not noticeable until
onersquos self-management is challenged by increased demands of adult life
EEGECG
Executive FunctionsDevelopment and Demands
bull In early childhood others perform all executive functions for the child (parents sibs and other caretakers)
bull Thereafter the child should be able (or is forced to) perform these functions for self
Onset before 7
PATHOGENESIS
summarybull structural and functional imaging studies
suggest that dysfunction of cingulate frontal and parietal cortical regions and imbalances in the dopaminergic and noradrenergic systems contribute to the pathophysiology of ADHD
Imaging Studies
1 Reduction of total brain size
2 Reduction of certain brain regions
3 Decrease blood flow in the striatum
4 Structural changes in the caudate and putamen
ADHD is a Chemical Problem
bull Dysfunction of dopaminergic and noradrenergic systems
bull Dopamine and norepinephrine are important in drugs that treat ADHD
In ADHD children the rate of glucosemetabolism in basal ganglions and in the frontal cortex is reduced
EF networks depends 1ry on 2 chemicals
Dopamine Norepinephrine
Not release and reload effectivelyMedications slow reuptake so longer in
contact with receptors
bull Methyl phenydate amp Atomoxetene
Mode of action
ndash prevents the reuptake of norepinephrine into the presynaptic neuron
X
AETIOLOGY
I AM A BUSY MOTHERor
WE ARE NOT A GOOD FAMILYor
HE IS A SPOILED BABY
1
1- Hereditary ADHD
Twin adoption
ADHD Is highly heritable
HEIGHT
ADHD
SCHIZOPHRENIA
IQ
DEPRESSION
DBH 5HTT SNAP-25
= dopamine transporter gene (DAT1)
= dopamine receptor gene (DRD)
D4
D5
= serotonin transporter gene5HTT
= others DBH HTR1Bm SNAP-25
2- Acquired Brain Injury
A prenatal Factors
CNS injury during Fetal Development
- Premature babies
-Traumainfectioncomplications
- Fetal exposure to drugs
- maternal smoking and maternal alcohol addiction
2- Acquired Brain Injury (cont)
B- CNS lesion during labour bull Type of Delivery can have impact if sudden or
extremely long and slow deliverybull Birth anoxia bull Weight at birth if SGA
C- Post Birth Factorsbull Cranial bleed bull Seizures bull Concussioncomabull Environmental chronic Lead poison
Environmental factors bull exposures to neurodevelopmental toxinstoxins
such as heavy metals and organohalide pollutants (lead mercury toxins -ldquoteratogensrdquo)
bull adverse responses to food additivesbull intolerances to foods (sugar )bull sensitivities to environmental chemicals
molds and fungi
Organochlorines and Child Development
bull Dichlorodiphenyl dichloroethylene(ppDDE) measured in umbilical cord blood
bull Serum levels were negatively associated with both mental and psychomotor development
bull The higher the serum level the worse the childs development at 13 months old
Recent studies suggest that causalpathways in some cases involve
complex interactions betweengenetic and environmental factors
2009
bull Less effective parenting - mother not in home father working more Everyone more stressed
bull Egypt educational curriculum and processbull Higher demands on childrenbull Toxins in the prenatal and early childhood environment (over
200 contaminants found in umbilical cord blood )
Why the Explosion in ADHD
MANAGEMENT
Recognition and Referral
OSHA PLAN OF MANAGEMENT
OF ADHD CHILD
Modified from AAP 2011
Recognition and Referral
Diagnosis (Assessment)
1+2+3
bull At present there is no biomedical laboratory test for ADHD
Neuropharmacology 57 (2009) 579ndash589
DD 70
DD for ADHD
bull 1- anxiety disordersbull 2- conduct disorderbull 3- oppositional defiant disorderbull 4- impulse-control or mood disordersbull 5- learning disordersbull 6- mental retardation
bull 7- gifted childrenbull 8- pervasive developmental disorders
DD for ADHD (contin)
bull 9- depression bull 10-Bipolar disorders Schizophrenia bull 11- Drugs PB CZP
bull 12- Misfits between the child and school or even the child and teacher
bull 13- substance abuse stimulants cocaine phenyclidine
bull 14- hyperthyroidismbull 15- BHL
bull
bull
Bip
ola
r D
iso
rder
Rule outs for the Diagnosis of ADHD
Myth ADHD child Can do bull Video Gamesbull Watch TVbull Computersbull Play Sportsbull Build Leggos
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
األخطاء تكرار على القدرة عدم
على المحافظةالنظافة و األدوات
التعليمات اتباع عدم بكثرة التحدث
SCHOOL AGE
ADHD Adolescence and Adult
15
85
undiagnosed
Occupational impairment increased family dysfunction driving risks and SUD
ADHD in Adolescence
bull Low self-esteembull Bad interpersonal relationships bull SUDbull Delinquency
Adult ADHD
bull Family bull Workbull Friendsbull Accidentbull Addiction
Attention-Deficit Disorder Isnt Just for Kids Why Adults Are Now Being Diagnosed Too
Wall Street Journal April 2010
What is ADHD
What is ADHD EF
Impairment of Executive Function set and development التنفيذى المدير
EF
(Six aspects domains)
OrganizingPrioritizing
AndActivatingTo work
FocusingSustaining
AndShifting attention
To task
RegulatingAlertness
Sustaining effortAnd
Processing speed
1-Activation
(planning and Organizing))
2-Focus
(persisting tasks)
3-Effort
(Starting ampstopping activity)
EF(cont)
Managing frustrationAnd
Modulating emotions
Utilizing working Memory
AndAccessing recall
Monitoring And
Self-regulatingaction
4-Emotion
(managing behavior)
5-Memory
(working memory)
6-Action
(Problem solving)
Effects of ADHD on EF
1-response inhibition
2- planning
3- time responseset shifting
4- working memory
5- inner talk
6- emotional stabilitylability
7- expectation
When are ADHDimpairments Noticeable
bull some preschoolbull Some middle elementary schoolbull Some college or later
Most in 1ry school
Executive Functionschallenges may reveal Weakness bull EF weakness may not noticeable until
onersquos self-management is challenged by increased demands of adult life
EEGECG
Executive FunctionsDevelopment and Demands
bull In early childhood others perform all executive functions for the child (parents sibs and other caretakers)
bull Thereafter the child should be able (or is forced to) perform these functions for self
Onset before 7
PATHOGENESIS
summarybull structural and functional imaging studies
suggest that dysfunction of cingulate frontal and parietal cortical regions and imbalances in the dopaminergic and noradrenergic systems contribute to the pathophysiology of ADHD
Imaging Studies
1 Reduction of total brain size
2 Reduction of certain brain regions
3 Decrease blood flow in the striatum
4 Structural changes in the caudate and putamen
ADHD is a Chemical Problem
bull Dysfunction of dopaminergic and noradrenergic systems
bull Dopamine and norepinephrine are important in drugs that treat ADHD
In ADHD children the rate of glucosemetabolism in basal ganglions and in the frontal cortex is reduced
EF networks depends 1ry on 2 chemicals
Dopamine Norepinephrine
Not release and reload effectivelyMedications slow reuptake so longer in
contact with receptors
bull Methyl phenydate amp Atomoxetene
Mode of action
ndash prevents the reuptake of norepinephrine into the presynaptic neuron
X
AETIOLOGY
I AM A BUSY MOTHERor
WE ARE NOT A GOOD FAMILYor
HE IS A SPOILED BABY
1
1- Hereditary ADHD
Twin adoption
ADHD Is highly heritable
HEIGHT
ADHD
SCHIZOPHRENIA
IQ
DEPRESSION
DBH 5HTT SNAP-25
= dopamine transporter gene (DAT1)
= dopamine receptor gene (DRD)
D4
D5
= serotonin transporter gene5HTT
= others DBH HTR1Bm SNAP-25
2- Acquired Brain Injury
A prenatal Factors
CNS injury during Fetal Development
- Premature babies
-Traumainfectioncomplications
- Fetal exposure to drugs
- maternal smoking and maternal alcohol addiction
2- Acquired Brain Injury (cont)
B- CNS lesion during labour bull Type of Delivery can have impact if sudden or
extremely long and slow deliverybull Birth anoxia bull Weight at birth if SGA
C- Post Birth Factorsbull Cranial bleed bull Seizures bull Concussioncomabull Environmental chronic Lead poison
Environmental factors bull exposures to neurodevelopmental toxinstoxins
such as heavy metals and organohalide pollutants (lead mercury toxins -ldquoteratogensrdquo)
bull adverse responses to food additivesbull intolerances to foods (sugar )bull sensitivities to environmental chemicals
molds and fungi
Organochlorines and Child Development
bull Dichlorodiphenyl dichloroethylene(ppDDE) measured in umbilical cord blood
bull Serum levels were negatively associated with both mental and psychomotor development
bull The higher the serum level the worse the childs development at 13 months old
Recent studies suggest that causalpathways in some cases involve
complex interactions betweengenetic and environmental factors
2009
bull Less effective parenting - mother not in home father working more Everyone more stressed
bull Egypt educational curriculum and processbull Higher demands on childrenbull Toxins in the prenatal and early childhood environment (over
200 contaminants found in umbilical cord blood )
Why the Explosion in ADHD
MANAGEMENT
Recognition and Referral
OSHA PLAN OF MANAGEMENT
OF ADHD CHILD
Modified from AAP 2011
Recognition and Referral
Diagnosis (Assessment)
1+2+3
bull At present there is no biomedical laboratory test for ADHD
Neuropharmacology 57 (2009) 579ndash589
DD 70
DD for ADHD
bull 1- anxiety disordersbull 2- conduct disorderbull 3- oppositional defiant disorderbull 4- impulse-control or mood disordersbull 5- learning disordersbull 6- mental retardation
bull 7- gifted childrenbull 8- pervasive developmental disorders
DD for ADHD (contin)
bull 9- depression bull 10-Bipolar disorders Schizophrenia bull 11- Drugs PB CZP
bull 12- Misfits between the child and school or even the child and teacher
bull 13- substance abuse stimulants cocaine phenyclidine
bull 14- hyperthyroidismbull 15- BHL
bull
bull
Bip
ola
r D
iso
rder
Rule outs for the Diagnosis of ADHD
Myth ADHD child Can do bull Video Gamesbull Watch TVbull Computersbull Play Sportsbull Build Leggos
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
ADHD Adolescence and Adult
15
85
undiagnosed
Occupational impairment increased family dysfunction driving risks and SUD
ADHD in Adolescence
bull Low self-esteembull Bad interpersonal relationships bull SUDbull Delinquency
Adult ADHD
bull Family bull Workbull Friendsbull Accidentbull Addiction
Attention-Deficit Disorder Isnt Just for Kids Why Adults Are Now Being Diagnosed Too
Wall Street Journal April 2010
What is ADHD
What is ADHD EF
Impairment of Executive Function set and development التنفيذى المدير
EF
(Six aspects domains)
OrganizingPrioritizing
AndActivatingTo work
FocusingSustaining
AndShifting attention
To task
RegulatingAlertness
Sustaining effortAnd
Processing speed
1-Activation
(planning and Organizing))
2-Focus
(persisting tasks)
3-Effort
(Starting ampstopping activity)
EF(cont)
Managing frustrationAnd
Modulating emotions
Utilizing working Memory
AndAccessing recall
Monitoring And
Self-regulatingaction
4-Emotion
(managing behavior)
5-Memory
(working memory)
6-Action
(Problem solving)
Effects of ADHD on EF
1-response inhibition
2- planning
3- time responseset shifting
4- working memory
5- inner talk
6- emotional stabilitylability
7- expectation
When are ADHDimpairments Noticeable
bull some preschoolbull Some middle elementary schoolbull Some college or later
Most in 1ry school
Executive Functionschallenges may reveal Weakness bull EF weakness may not noticeable until
onersquos self-management is challenged by increased demands of adult life
EEGECG
Executive FunctionsDevelopment and Demands
bull In early childhood others perform all executive functions for the child (parents sibs and other caretakers)
bull Thereafter the child should be able (or is forced to) perform these functions for self
Onset before 7
PATHOGENESIS
summarybull structural and functional imaging studies
suggest that dysfunction of cingulate frontal and parietal cortical regions and imbalances in the dopaminergic and noradrenergic systems contribute to the pathophysiology of ADHD
Imaging Studies
1 Reduction of total brain size
2 Reduction of certain brain regions
3 Decrease blood flow in the striatum
4 Structural changes in the caudate and putamen
ADHD is a Chemical Problem
bull Dysfunction of dopaminergic and noradrenergic systems
bull Dopamine and norepinephrine are important in drugs that treat ADHD
In ADHD children the rate of glucosemetabolism in basal ganglions and in the frontal cortex is reduced
EF networks depends 1ry on 2 chemicals
Dopamine Norepinephrine
Not release and reload effectivelyMedications slow reuptake so longer in
contact with receptors
bull Methyl phenydate amp Atomoxetene
Mode of action
ndash prevents the reuptake of norepinephrine into the presynaptic neuron
X
AETIOLOGY
I AM A BUSY MOTHERor
WE ARE NOT A GOOD FAMILYor
HE IS A SPOILED BABY
1
1- Hereditary ADHD
Twin adoption
ADHD Is highly heritable
HEIGHT
ADHD
SCHIZOPHRENIA
IQ
DEPRESSION
DBH 5HTT SNAP-25
= dopamine transporter gene (DAT1)
= dopamine receptor gene (DRD)
D4
D5
= serotonin transporter gene5HTT
= others DBH HTR1Bm SNAP-25
2- Acquired Brain Injury
A prenatal Factors
CNS injury during Fetal Development
- Premature babies
-Traumainfectioncomplications
- Fetal exposure to drugs
- maternal smoking and maternal alcohol addiction
2- Acquired Brain Injury (cont)
B- CNS lesion during labour bull Type of Delivery can have impact if sudden or
extremely long and slow deliverybull Birth anoxia bull Weight at birth if SGA
C- Post Birth Factorsbull Cranial bleed bull Seizures bull Concussioncomabull Environmental chronic Lead poison
Environmental factors bull exposures to neurodevelopmental toxinstoxins
such as heavy metals and organohalide pollutants (lead mercury toxins -ldquoteratogensrdquo)
bull adverse responses to food additivesbull intolerances to foods (sugar )bull sensitivities to environmental chemicals
molds and fungi
Organochlorines and Child Development
bull Dichlorodiphenyl dichloroethylene(ppDDE) measured in umbilical cord blood
bull Serum levels were negatively associated with both mental and psychomotor development
bull The higher the serum level the worse the childs development at 13 months old
Recent studies suggest that causalpathways in some cases involve
complex interactions betweengenetic and environmental factors
2009
bull Less effective parenting - mother not in home father working more Everyone more stressed
bull Egypt educational curriculum and processbull Higher demands on childrenbull Toxins in the prenatal and early childhood environment (over
200 contaminants found in umbilical cord blood )
Why the Explosion in ADHD
MANAGEMENT
Recognition and Referral
OSHA PLAN OF MANAGEMENT
OF ADHD CHILD
Modified from AAP 2011
Recognition and Referral
Diagnosis (Assessment)
1+2+3
bull At present there is no biomedical laboratory test for ADHD
Neuropharmacology 57 (2009) 579ndash589
DD 70
DD for ADHD
bull 1- anxiety disordersbull 2- conduct disorderbull 3- oppositional defiant disorderbull 4- impulse-control or mood disordersbull 5- learning disordersbull 6- mental retardation
bull 7- gifted childrenbull 8- pervasive developmental disorders
DD for ADHD (contin)
bull 9- depression bull 10-Bipolar disorders Schizophrenia bull 11- Drugs PB CZP
bull 12- Misfits between the child and school or even the child and teacher
bull 13- substance abuse stimulants cocaine phenyclidine
bull 14- hyperthyroidismbull 15- BHL
bull
bull
Bip
ola
r D
iso
rder
Rule outs for the Diagnosis of ADHD
Myth ADHD child Can do bull Video Gamesbull Watch TVbull Computersbull Play Sportsbull Build Leggos
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
ADHD in Adolescence
bull Low self-esteembull Bad interpersonal relationships bull SUDbull Delinquency
Adult ADHD
bull Family bull Workbull Friendsbull Accidentbull Addiction
Attention-Deficit Disorder Isnt Just for Kids Why Adults Are Now Being Diagnosed Too
Wall Street Journal April 2010
What is ADHD
What is ADHD EF
Impairment of Executive Function set and development التنفيذى المدير
EF
(Six aspects domains)
OrganizingPrioritizing
AndActivatingTo work
FocusingSustaining
AndShifting attention
To task
RegulatingAlertness
Sustaining effortAnd
Processing speed
1-Activation
(planning and Organizing))
2-Focus
(persisting tasks)
3-Effort
(Starting ampstopping activity)
EF(cont)
Managing frustrationAnd
Modulating emotions
Utilizing working Memory
AndAccessing recall
Monitoring And
Self-regulatingaction
4-Emotion
(managing behavior)
5-Memory
(working memory)
6-Action
(Problem solving)
Effects of ADHD on EF
1-response inhibition
2- planning
3- time responseset shifting
4- working memory
5- inner talk
6- emotional stabilitylability
7- expectation
When are ADHDimpairments Noticeable
bull some preschoolbull Some middle elementary schoolbull Some college or later
Most in 1ry school
Executive Functionschallenges may reveal Weakness bull EF weakness may not noticeable until
onersquos self-management is challenged by increased demands of adult life
EEGECG
Executive FunctionsDevelopment and Demands
bull In early childhood others perform all executive functions for the child (parents sibs and other caretakers)
bull Thereafter the child should be able (or is forced to) perform these functions for self
Onset before 7
PATHOGENESIS
summarybull structural and functional imaging studies
suggest that dysfunction of cingulate frontal and parietal cortical regions and imbalances in the dopaminergic and noradrenergic systems contribute to the pathophysiology of ADHD
Imaging Studies
1 Reduction of total brain size
2 Reduction of certain brain regions
3 Decrease blood flow in the striatum
4 Structural changes in the caudate and putamen
ADHD is a Chemical Problem
bull Dysfunction of dopaminergic and noradrenergic systems
bull Dopamine and norepinephrine are important in drugs that treat ADHD
In ADHD children the rate of glucosemetabolism in basal ganglions and in the frontal cortex is reduced
EF networks depends 1ry on 2 chemicals
Dopamine Norepinephrine
Not release and reload effectivelyMedications slow reuptake so longer in
contact with receptors
bull Methyl phenydate amp Atomoxetene
Mode of action
ndash prevents the reuptake of norepinephrine into the presynaptic neuron
X
AETIOLOGY
I AM A BUSY MOTHERor
WE ARE NOT A GOOD FAMILYor
HE IS A SPOILED BABY
1
1- Hereditary ADHD
Twin adoption
ADHD Is highly heritable
HEIGHT
ADHD
SCHIZOPHRENIA
IQ
DEPRESSION
DBH 5HTT SNAP-25
= dopamine transporter gene (DAT1)
= dopamine receptor gene (DRD)
D4
D5
= serotonin transporter gene5HTT
= others DBH HTR1Bm SNAP-25
2- Acquired Brain Injury
A prenatal Factors
CNS injury during Fetal Development
- Premature babies
-Traumainfectioncomplications
- Fetal exposure to drugs
- maternal smoking and maternal alcohol addiction
2- Acquired Brain Injury (cont)
B- CNS lesion during labour bull Type of Delivery can have impact if sudden or
extremely long and slow deliverybull Birth anoxia bull Weight at birth if SGA
C- Post Birth Factorsbull Cranial bleed bull Seizures bull Concussioncomabull Environmental chronic Lead poison
Environmental factors bull exposures to neurodevelopmental toxinstoxins
such as heavy metals and organohalide pollutants (lead mercury toxins -ldquoteratogensrdquo)
bull adverse responses to food additivesbull intolerances to foods (sugar )bull sensitivities to environmental chemicals
molds and fungi
Organochlorines and Child Development
bull Dichlorodiphenyl dichloroethylene(ppDDE) measured in umbilical cord blood
bull Serum levels were negatively associated with both mental and psychomotor development
bull The higher the serum level the worse the childs development at 13 months old
Recent studies suggest that causalpathways in some cases involve
complex interactions betweengenetic and environmental factors
2009
bull Less effective parenting - mother not in home father working more Everyone more stressed
bull Egypt educational curriculum and processbull Higher demands on childrenbull Toxins in the prenatal and early childhood environment (over
200 contaminants found in umbilical cord blood )
Why the Explosion in ADHD
MANAGEMENT
Recognition and Referral
OSHA PLAN OF MANAGEMENT
OF ADHD CHILD
Modified from AAP 2011
Recognition and Referral
Diagnosis (Assessment)
1+2+3
bull At present there is no biomedical laboratory test for ADHD
Neuropharmacology 57 (2009) 579ndash589
DD 70
DD for ADHD
bull 1- anxiety disordersbull 2- conduct disorderbull 3- oppositional defiant disorderbull 4- impulse-control or mood disordersbull 5- learning disordersbull 6- mental retardation
bull 7- gifted childrenbull 8- pervasive developmental disorders
DD for ADHD (contin)
bull 9- depression bull 10-Bipolar disorders Schizophrenia bull 11- Drugs PB CZP
bull 12- Misfits between the child and school or even the child and teacher
bull 13- substance abuse stimulants cocaine phenyclidine
bull 14- hyperthyroidismbull 15- BHL
bull
bull
Bip
ola
r D
iso
rder
Rule outs for the Diagnosis of ADHD
Myth ADHD child Can do bull Video Gamesbull Watch TVbull Computersbull Play Sportsbull Build Leggos
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
Adult ADHD
bull Family bull Workbull Friendsbull Accidentbull Addiction
Attention-Deficit Disorder Isnt Just for Kids Why Adults Are Now Being Diagnosed Too
Wall Street Journal April 2010
What is ADHD
What is ADHD EF
Impairment of Executive Function set and development التنفيذى المدير
EF
(Six aspects domains)
OrganizingPrioritizing
AndActivatingTo work
FocusingSustaining
AndShifting attention
To task
RegulatingAlertness
Sustaining effortAnd
Processing speed
1-Activation
(planning and Organizing))
2-Focus
(persisting tasks)
3-Effort
(Starting ampstopping activity)
EF(cont)
Managing frustrationAnd
Modulating emotions
Utilizing working Memory
AndAccessing recall
Monitoring And
Self-regulatingaction
4-Emotion
(managing behavior)
5-Memory
(working memory)
6-Action
(Problem solving)
Effects of ADHD on EF
1-response inhibition
2- planning
3- time responseset shifting
4- working memory
5- inner talk
6- emotional stabilitylability
7- expectation
When are ADHDimpairments Noticeable
bull some preschoolbull Some middle elementary schoolbull Some college or later
Most in 1ry school
Executive Functionschallenges may reveal Weakness bull EF weakness may not noticeable until
onersquos self-management is challenged by increased demands of adult life
EEGECG
Executive FunctionsDevelopment and Demands
bull In early childhood others perform all executive functions for the child (parents sibs and other caretakers)
bull Thereafter the child should be able (or is forced to) perform these functions for self
Onset before 7
PATHOGENESIS
summarybull structural and functional imaging studies
suggest that dysfunction of cingulate frontal and parietal cortical regions and imbalances in the dopaminergic and noradrenergic systems contribute to the pathophysiology of ADHD
Imaging Studies
1 Reduction of total brain size
2 Reduction of certain brain regions
3 Decrease blood flow in the striatum
4 Structural changes in the caudate and putamen
ADHD is a Chemical Problem
bull Dysfunction of dopaminergic and noradrenergic systems
bull Dopamine and norepinephrine are important in drugs that treat ADHD
In ADHD children the rate of glucosemetabolism in basal ganglions and in the frontal cortex is reduced
EF networks depends 1ry on 2 chemicals
Dopamine Norepinephrine
Not release and reload effectivelyMedications slow reuptake so longer in
contact with receptors
bull Methyl phenydate amp Atomoxetene
Mode of action
ndash prevents the reuptake of norepinephrine into the presynaptic neuron
X
AETIOLOGY
I AM A BUSY MOTHERor
WE ARE NOT A GOOD FAMILYor
HE IS A SPOILED BABY
1
1- Hereditary ADHD
Twin adoption
ADHD Is highly heritable
HEIGHT
ADHD
SCHIZOPHRENIA
IQ
DEPRESSION
DBH 5HTT SNAP-25
= dopamine transporter gene (DAT1)
= dopamine receptor gene (DRD)
D4
D5
= serotonin transporter gene5HTT
= others DBH HTR1Bm SNAP-25
2- Acquired Brain Injury
A prenatal Factors
CNS injury during Fetal Development
- Premature babies
-Traumainfectioncomplications
- Fetal exposure to drugs
- maternal smoking and maternal alcohol addiction
2- Acquired Brain Injury (cont)
B- CNS lesion during labour bull Type of Delivery can have impact if sudden or
extremely long and slow deliverybull Birth anoxia bull Weight at birth if SGA
C- Post Birth Factorsbull Cranial bleed bull Seizures bull Concussioncomabull Environmental chronic Lead poison
Environmental factors bull exposures to neurodevelopmental toxinstoxins
such as heavy metals and organohalide pollutants (lead mercury toxins -ldquoteratogensrdquo)
bull adverse responses to food additivesbull intolerances to foods (sugar )bull sensitivities to environmental chemicals
molds and fungi
Organochlorines and Child Development
bull Dichlorodiphenyl dichloroethylene(ppDDE) measured in umbilical cord blood
bull Serum levels were negatively associated with both mental and psychomotor development
bull The higher the serum level the worse the childs development at 13 months old
Recent studies suggest that causalpathways in some cases involve
complex interactions betweengenetic and environmental factors
2009
bull Less effective parenting - mother not in home father working more Everyone more stressed
bull Egypt educational curriculum and processbull Higher demands on childrenbull Toxins in the prenatal and early childhood environment (over
200 contaminants found in umbilical cord blood )
Why the Explosion in ADHD
MANAGEMENT
Recognition and Referral
OSHA PLAN OF MANAGEMENT
OF ADHD CHILD
Modified from AAP 2011
Recognition and Referral
Diagnosis (Assessment)
1+2+3
bull At present there is no biomedical laboratory test for ADHD
Neuropharmacology 57 (2009) 579ndash589
DD 70
DD for ADHD
bull 1- anxiety disordersbull 2- conduct disorderbull 3- oppositional defiant disorderbull 4- impulse-control or mood disordersbull 5- learning disordersbull 6- mental retardation
bull 7- gifted childrenbull 8- pervasive developmental disorders
DD for ADHD (contin)
bull 9- depression bull 10-Bipolar disorders Schizophrenia bull 11- Drugs PB CZP
bull 12- Misfits between the child and school or even the child and teacher
bull 13- substance abuse stimulants cocaine phenyclidine
bull 14- hyperthyroidismbull 15- BHL
bull
bull
Bip
ola
r D
iso
rder
Rule outs for the Diagnosis of ADHD
Myth ADHD child Can do bull Video Gamesbull Watch TVbull Computersbull Play Sportsbull Build Leggos
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
What is ADHD
What is ADHD EF
Impairment of Executive Function set and development التنفيذى المدير
EF
(Six aspects domains)
OrganizingPrioritizing
AndActivatingTo work
FocusingSustaining
AndShifting attention
To task
RegulatingAlertness
Sustaining effortAnd
Processing speed
1-Activation
(planning and Organizing))
2-Focus
(persisting tasks)
3-Effort
(Starting ampstopping activity)
EF(cont)
Managing frustrationAnd
Modulating emotions
Utilizing working Memory
AndAccessing recall
Monitoring And
Self-regulatingaction
4-Emotion
(managing behavior)
5-Memory
(working memory)
6-Action
(Problem solving)
Effects of ADHD on EF
1-response inhibition
2- planning
3- time responseset shifting
4- working memory
5- inner talk
6- emotional stabilitylability
7- expectation
When are ADHDimpairments Noticeable
bull some preschoolbull Some middle elementary schoolbull Some college or later
Most in 1ry school
Executive Functionschallenges may reveal Weakness bull EF weakness may not noticeable until
onersquos self-management is challenged by increased demands of adult life
EEGECG
Executive FunctionsDevelopment and Demands
bull In early childhood others perform all executive functions for the child (parents sibs and other caretakers)
bull Thereafter the child should be able (or is forced to) perform these functions for self
Onset before 7
PATHOGENESIS
summarybull structural and functional imaging studies
suggest that dysfunction of cingulate frontal and parietal cortical regions and imbalances in the dopaminergic and noradrenergic systems contribute to the pathophysiology of ADHD
Imaging Studies
1 Reduction of total brain size
2 Reduction of certain brain regions
3 Decrease blood flow in the striatum
4 Structural changes in the caudate and putamen
ADHD is a Chemical Problem
bull Dysfunction of dopaminergic and noradrenergic systems
bull Dopamine and norepinephrine are important in drugs that treat ADHD
In ADHD children the rate of glucosemetabolism in basal ganglions and in the frontal cortex is reduced
EF networks depends 1ry on 2 chemicals
Dopamine Norepinephrine
Not release and reload effectivelyMedications slow reuptake so longer in
contact with receptors
bull Methyl phenydate amp Atomoxetene
Mode of action
ndash prevents the reuptake of norepinephrine into the presynaptic neuron
X
AETIOLOGY
I AM A BUSY MOTHERor
WE ARE NOT A GOOD FAMILYor
HE IS A SPOILED BABY
1
1- Hereditary ADHD
Twin adoption
ADHD Is highly heritable
HEIGHT
ADHD
SCHIZOPHRENIA
IQ
DEPRESSION
DBH 5HTT SNAP-25
= dopamine transporter gene (DAT1)
= dopamine receptor gene (DRD)
D4
D5
= serotonin transporter gene5HTT
= others DBH HTR1Bm SNAP-25
2- Acquired Brain Injury
A prenatal Factors
CNS injury during Fetal Development
- Premature babies
-Traumainfectioncomplications
- Fetal exposure to drugs
- maternal smoking and maternal alcohol addiction
2- Acquired Brain Injury (cont)
B- CNS lesion during labour bull Type of Delivery can have impact if sudden or
extremely long and slow deliverybull Birth anoxia bull Weight at birth if SGA
C- Post Birth Factorsbull Cranial bleed bull Seizures bull Concussioncomabull Environmental chronic Lead poison
Environmental factors bull exposures to neurodevelopmental toxinstoxins
such as heavy metals and organohalide pollutants (lead mercury toxins -ldquoteratogensrdquo)
bull adverse responses to food additivesbull intolerances to foods (sugar )bull sensitivities to environmental chemicals
molds and fungi
Organochlorines and Child Development
bull Dichlorodiphenyl dichloroethylene(ppDDE) measured in umbilical cord blood
bull Serum levels were negatively associated with both mental and psychomotor development
bull The higher the serum level the worse the childs development at 13 months old
Recent studies suggest that causalpathways in some cases involve
complex interactions betweengenetic and environmental factors
2009
bull Less effective parenting - mother not in home father working more Everyone more stressed
bull Egypt educational curriculum and processbull Higher demands on childrenbull Toxins in the prenatal and early childhood environment (over
200 contaminants found in umbilical cord blood )
Why the Explosion in ADHD
MANAGEMENT
Recognition and Referral
OSHA PLAN OF MANAGEMENT
OF ADHD CHILD
Modified from AAP 2011
Recognition and Referral
Diagnosis (Assessment)
1+2+3
bull At present there is no biomedical laboratory test for ADHD
Neuropharmacology 57 (2009) 579ndash589
DD 70
DD for ADHD
bull 1- anxiety disordersbull 2- conduct disorderbull 3- oppositional defiant disorderbull 4- impulse-control or mood disordersbull 5- learning disordersbull 6- mental retardation
bull 7- gifted childrenbull 8- pervasive developmental disorders
DD for ADHD (contin)
bull 9- depression bull 10-Bipolar disorders Schizophrenia bull 11- Drugs PB CZP
bull 12- Misfits between the child and school or even the child and teacher
bull 13- substance abuse stimulants cocaine phenyclidine
bull 14- hyperthyroidismbull 15- BHL
bull
bull
Bip
ola
r D
iso
rder
Rule outs for the Diagnosis of ADHD
Myth ADHD child Can do bull Video Gamesbull Watch TVbull Computersbull Play Sportsbull Build Leggos
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
What is ADHD EF
Impairment of Executive Function set and development التنفيذى المدير
EF
(Six aspects domains)
OrganizingPrioritizing
AndActivatingTo work
FocusingSustaining
AndShifting attention
To task
RegulatingAlertness
Sustaining effortAnd
Processing speed
1-Activation
(planning and Organizing))
2-Focus
(persisting tasks)
3-Effort
(Starting ampstopping activity)
EF(cont)
Managing frustrationAnd
Modulating emotions
Utilizing working Memory
AndAccessing recall
Monitoring And
Self-regulatingaction
4-Emotion
(managing behavior)
5-Memory
(working memory)
6-Action
(Problem solving)
Effects of ADHD on EF
1-response inhibition
2- planning
3- time responseset shifting
4- working memory
5- inner talk
6- emotional stabilitylability
7- expectation
When are ADHDimpairments Noticeable
bull some preschoolbull Some middle elementary schoolbull Some college or later
Most in 1ry school
Executive Functionschallenges may reveal Weakness bull EF weakness may not noticeable until
onersquos self-management is challenged by increased demands of adult life
EEGECG
Executive FunctionsDevelopment and Demands
bull In early childhood others perform all executive functions for the child (parents sibs and other caretakers)
bull Thereafter the child should be able (or is forced to) perform these functions for self
Onset before 7
PATHOGENESIS
summarybull structural and functional imaging studies
suggest that dysfunction of cingulate frontal and parietal cortical regions and imbalances in the dopaminergic and noradrenergic systems contribute to the pathophysiology of ADHD
Imaging Studies
1 Reduction of total brain size
2 Reduction of certain brain regions
3 Decrease blood flow in the striatum
4 Structural changes in the caudate and putamen
ADHD is a Chemical Problem
bull Dysfunction of dopaminergic and noradrenergic systems
bull Dopamine and norepinephrine are important in drugs that treat ADHD
In ADHD children the rate of glucosemetabolism in basal ganglions and in the frontal cortex is reduced
EF networks depends 1ry on 2 chemicals
Dopamine Norepinephrine
Not release and reload effectivelyMedications slow reuptake so longer in
contact with receptors
bull Methyl phenydate amp Atomoxetene
Mode of action
ndash prevents the reuptake of norepinephrine into the presynaptic neuron
X
AETIOLOGY
I AM A BUSY MOTHERor
WE ARE NOT A GOOD FAMILYor
HE IS A SPOILED BABY
1
1- Hereditary ADHD
Twin adoption
ADHD Is highly heritable
HEIGHT
ADHD
SCHIZOPHRENIA
IQ
DEPRESSION
DBH 5HTT SNAP-25
= dopamine transporter gene (DAT1)
= dopamine receptor gene (DRD)
D4
D5
= serotonin transporter gene5HTT
= others DBH HTR1Bm SNAP-25
2- Acquired Brain Injury
A prenatal Factors
CNS injury during Fetal Development
- Premature babies
-Traumainfectioncomplications
- Fetal exposure to drugs
- maternal smoking and maternal alcohol addiction
2- Acquired Brain Injury (cont)
B- CNS lesion during labour bull Type of Delivery can have impact if sudden or
extremely long and slow deliverybull Birth anoxia bull Weight at birth if SGA
C- Post Birth Factorsbull Cranial bleed bull Seizures bull Concussioncomabull Environmental chronic Lead poison
Environmental factors bull exposures to neurodevelopmental toxinstoxins
such as heavy metals and organohalide pollutants (lead mercury toxins -ldquoteratogensrdquo)
bull adverse responses to food additivesbull intolerances to foods (sugar )bull sensitivities to environmental chemicals
molds and fungi
Organochlorines and Child Development
bull Dichlorodiphenyl dichloroethylene(ppDDE) measured in umbilical cord blood
bull Serum levels were negatively associated with both mental and psychomotor development
bull The higher the serum level the worse the childs development at 13 months old
Recent studies suggest that causalpathways in some cases involve
complex interactions betweengenetic and environmental factors
2009
bull Less effective parenting - mother not in home father working more Everyone more stressed
bull Egypt educational curriculum and processbull Higher demands on childrenbull Toxins in the prenatal and early childhood environment (over
200 contaminants found in umbilical cord blood )
Why the Explosion in ADHD
MANAGEMENT
Recognition and Referral
OSHA PLAN OF MANAGEMENT
OF ADHD CHILD
Modified from AAP 2011
Recognition and Referral
Diagnosis (Assessment)
1+2+3
bull At present there is no biomedical laboratory test for ADHD
Neuropharmacology 57 (2009) 579ndash589
DD 70
DD for ADHD
bull 1- anxiety disordersbull 2- conduct disorderbull 3- oppositional defiant disorderbull 4- impulse-control or mood disordersbull 5- learning disordersbull 6- mental retardation
bull 7- gifted childrenbull 8- pervasive developmental disorders
DD for ADHD (contin)
bull 9- depression bull 10-Bipolar disorders Schizophrenia bull 11- Drugs PB CZP
bull 12- Misfits between the child and school or even the child and teacher
bull 13- substance abuse stimulants cocaine phenyclidine
bull 14- hyperthyroidismbull 15- BHL
bull
bull
Bip
ola
r D
iso
rder
Rule outs for the Diagnosis of ADHD
Myth ADHD child Can do bull Video Gamesbull Watch TVbull Computersbull Play Sportsbull Build Leggos
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
EF
(Six aspects domains)
OrganizingPrioritizing
AndActivatingTo work
FocusingSustaining
AndShifting attention
To task
RegulatingAlertness
Sustaining effortAnd
Processing speed
1-Activation
(planning and Organizing))
2-Focus
(persisting tasks)
3-Effort
(Starting ampstopping activity)
EF(cont)
Managing frustrationAnd
Modulating emotions
Utilizing working Memory
AndAccessing recall
Monitoring And
Self-regulatingaction
4-Emotion
(managing behavior)
5-Memory
(working memory)
6-Action
(Problem solving)
Effects of ADHD on EF
1-response inhibition
2- planning
3- time responseset shifting
4- working memory
5- inner talk
6- emotional stabilitylability
7- expectation
When are ADHDimpairments Noticeable
bull some preschoolbull Some middle elementary schoolbull Some college or later
Most in 1ry school
Executive Functionschallenges may reveal Weakness bull EF weakness may not noticeable until
onersquos self-management is challenged by increased demands of adult life
EEGECG
Executive FunctionsDevelopment and Demands
bull In early childhood others perform all executive functions for the child (parents sibs and other caretakers)
bull Thereafter the child should be able (or is forced to) perform these functions for self
Onset before 7
PATHOGENESIS
summarybull structural and functional imaging studies
suggest that dysfunction of cingulate frontal and parietal cortical regions and imbalances in the dopaminergic and noradrenergic systems contribute to the pathophysiology of ADHD
Imaging Studies
1 Reduction of total brain size
2 Reduction of certain brain regions
3 Decrease blood flow in the striatum
4 Structural changes in the caudate and putamen
ADHD is a Chemical Problem
bull Dysfunction of dopaminergic and noradrenergic systems
bull Dopamine and norepinephrine are important in drugs that treat ADHD
In ADHD children the rate of glucosemetabolism in basal ganglions and in the frontal cortex is reduced
EF networks depends 1ry on 2 chemicals
Dopamine Norepinephrine
Not release and reload effectivelyMedications slow reuptake so longer in
contact with receptors
bull Methyl phenydate amp Atomoxetene
Mode of action
ndash prevents the reuptake of norepinephrine into the presynaptic neuron
X
AETIOLOGY
I AM A BUSY MOTHERor
WE ARE NOT A GOOD FAMILYor
HE IS A SPOILED BABY
1
1- Hereditary ADHD
Twin adoption
ADHD Is highly heritable
HEIGHT
ADHD
SCHIZOPHRENIA
IQ
DEPRESSION
DBH 5HTT SNAP-25
= dopamine transporter gene (DAT1)
= dopamine receptor gene (DRD)
D4
D5
= serotonin transporter gene5HTT
= others DBH HTR1Bm SNAP-25
2- Acquired Brain Injury
A prenatal Factors
CNS injury during Fetal Development
- Premature babies
-Traumainfectioncomplications
- Fetal exposure to drugs
- maternal smoking and maternal alcohol addiction
2- Acquired Brain Injury (cont)
B- CNS lesion during labour bull Type of Delivery can have impact if sudden or
extremely long and slow deliverybull Birth anoxia bull Weight at birth if SGA
C- Post Birth Factorsbull Cranial bleed bull Seizures bull Concussioncomabull Environmental chronic Lead poison
Environmental factors bull exposures to neurodevelopmental toxinstoxins
such as heavy metals and organohalide pollutants (lead mercury toxins -ldquoteratogensrdquo)
bull adverse responses to food additivesbull intolerances to foods (sugar )bull sensitivities to environmental chemicals
molds and fungi
Organochlorines and Child Development
bull Dichlorodiphenyl dichloroethylene(ppDDE) measured in umbilical cord blood
bull Serum levels were negatively associated with both mental and psychomotor development
bull The higher the serum level the worse the childs development at 13 months old
Recent studies suggest that causalpathways in some cases involve
complex interactions betweengenetic and environmental factors
2009
bull Less effective parenting - mother not in home father working more Everyone more stressed
bull Egypt educational curriculum and processbull Higher demands on childrenbull Toxins in the prenatal and early childhood environment (over
200 contaminants found in umbilical cord blood )
Why the Explosion in ADHD
MANAGEMENT
Recognition and Referral
OSHA PLAN OF MANAGEMENT
OF ADHD CHILD
Modified from AAP 2011
Recognition and Referral
Diagnosis (Assessment)
1+2+3
bull At present there is no biomedical laboratory test for ADHD
Neuropharmacology 57 (2009) 579ndash589
DD 70
DD for ADHD
bull 1- anxiety disordersbull 2- conduct disorderbull 3- oppositional defiant disorderbull 4- impulse-control or mood disordersbull 5- learning disordersbull 6- mental retardation
bull 7- gifted childrenbull 8- pervasive developmental disorders
DD for ADHD (contin)
bull 9- depression bull 10-Bipolar disorders Schizophrenia bull 11- Drugs PB CZP
bull 12- Misfits between the child and school or even the child and teacher
bull 13- substance abuse stimulants cocaine phenyclidine
bull 14- hyperthyroidismbull 15- BHL
bull
bull
Bip
ola
r D
iso
rder
Rule outs for the Diagnosis of ADHD
Myth ADHD child Can do bull Video Gamesbull Watch TVbull Computersbull Play Sportsbull Build Leggos
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
EF(cont)
Managing frustrationAnd
Modulating emotions
Utilizing working Memory
AndAccessing recall
Monitoring And
Self-regulatingaction
4-Emotion
(managing behavior)
5-Memory
(working memory)
6-Action
(Problem solving)
Effects of ADHD on EF
1-response inhibition
2- planning
3- time responseset shifting
4- working memory
5- inner talk
6- emotional stabilitylability
7- expectation
When are ADHDimpairments Noticeable
bull some preschoolbull Some middle elementary schoolbull Some college or later
Most in 1ry school
Executive Functionschallenges may reveal Weakness bull EF weakness may not noticeable until
onersquos self-management is challenged by increased demands of adult life
EEGECG
Executive FunctionsDevelopment and Demands
bull In early childhood others perform all executive functions for the child (parents sibs and other caretakers)
bull Thereafter the child should be able (or is forced to) perform these functions for self
Onset before 7
PATHOGENESIS
summarybull structural and functional imaging studies
suggest that dysfunction of cingulate frontal and parietal cortical regions and imbalances in the dopaminergic and noradrenergic systems contribute to the pathophysiology of ADHD
Imaging Studies
1 Reduction of total brain size
2 Reduction of certain brain regions
3 Decrease blood flow in the striatum
4 Structural changes in the caudate and putamen
ADHD is a Chemical Problem
bull Dysfunction of dopaminergic and noradrenergic systems
bull Dopamine and norepinephrine are important in drugs that treat ADHD
In ADHD children the rate of glucosemetabolism in basal ganglions and in the frontal cortex is reduced
EF networks depends 1ry on 2 chemicals
Dopamine Norepinephrine
Not release and reload effectivelyMedications slow reuptake so longer in
contact with receptors
bull Methyl phenydate amp Atomoxetene
Mode of action
ndash prevents the reuptake of norepinephrine into the presynaptic neuron
X
AETIOLOGY
I AM A BUSY MOTHERor
WE ARE NOT A GOOD FAMILYor
HE IS A SPOILED BABY
1
1- Hereditary ADHD
Twin adoption
ADHD Is highly heritable
HEIGHT
ADHD
SCHIZOPHRENIA
IQ
DEPRESSION
DBH 5HTT SNAP-25
= dopamine transporter gene (DAT1)
= dopamine receptor gene (DRD)
D4
D5
= serotonin transporter gene5HTT
= others DBH HTR1Bm SNAP-25
2- Acquired Brain Injury
A prenatal Factors
CNS injury during Fetal Development
- Premature babies
-Traumainfectioncomplications
- Fetal exposure to drugs
- maternal smoking and maternal alcohol addiction
2- Acquired Brain Injury (cont)
B- CNS lesion during labour bull Type of Delivery can have impact if sudden or
extremely long and slow deliverybull Birth anoxia bull Weight at birth if SGA
C- Post Birth Factorsbull Cranial bleed bull Seizures bull Concussioncomabull Environmental chronic Lead poison
Environmental factors bull exposures to neurodevelopmental toxinstoxins
such as heavy metals and organohalide pollutants (lead mercury toxins -ldquoteratogensrdquo)
bull adverse responses to food additivesbull intolerances to foods (sugar )bull sensitivities to environmental chemicals
molds and fungi
Organochlorines and Child Development
bull Dichlorodiphenyl dichloroethylene(ppDDE) measured in umbilical cord blood
bull Serum levels were negatively associated with both mental and psychomotor development
bull The higher the serum level the worse the childs development at 13 months old
Recent studies suggest that causalpathways in some cases involve
complex interactions betweengenetic and environmental factors
2009
bull Less effective parenting - mother not in home father working more Everyone more stressed
bull Egypt educational curriculum and processbull Higher demands on childrenbull Toxins in the prenatal and early childhood environment (over
200 contaminants found in umbilical cord blood )
Why the Explosion in ADHD
MANAGEMENT
Recognition and Referral
OSHA PLAN OF MANAGEMENT
OF ADHD CHILD
Modified from AAP 2011
Recognition and Referral
Diagnosis (Assessment)
1+2+3
bull At present there is no biomedical laboratory test for ADHD
Neuropharmacology 57 (2009) 579ndash589
DD 70
DD for ADHD
bull 1- anxiety disordersbull 2- conduct disorderbull 3- oppositional defiant disorderbull 4- impulse-control or mood disordersbull 5- learning disordersbull 6- mental retardation
bull 7- gifted childrenbull 8- pervasive developmental disorders
DD for ADHD (contin)
bull 9- depression bull 10-Bipolar disorders Schizophrenia bull 11- Drugs PB CZP
bull 12- Misfits between the child and school or even the child and teacher
bull 13- substance abuse stimulants cocaine phenyclidine
bull 14- hyperthyroidismbull 15- BHL
bull
bull
Bip
ola
r D
iso
rder
Rule outs for the Diagnosis of ADHD
Myth ADHD child Can do bull Video Gamesbull Watch TVbull Computersbull Play Sportsbull Build Leggos
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
Effects of ADHD on EF
1-response inhibition
2- planning
3- time responseset shifting
4- working memory
5- inner talk
6- emotional stabilitylability
7- expectation
When are ADHDimpairments Noticeable
bull some preschoolbull Some middle elementary schoolbull Some college or later
Most in 1ry school
Executive Functionschallenges may reveal Weakness bull EF weakness may not noticeable until
onersquos self-management is challenged by increased demands of adult life
EEGECG
Executive FunctionsDevelopment and Demands
bull In early childhood others perform all executive functions for the child (parents sibs and other caretakers)
bull Thereafter the child should be able (or is forced to) perform these functions for self
Onset before 7
PATHOGENESIS
summarybull structural and functional imaging studies
suggest that dysfunction of cingulate frontal and parietal cortical regions and imbalances in the dopaminergic and noradrenergic systems contribute to the pathophysiology of ADHD
Imaging Studies
1 Reduction of total brain size
2 Reduction of certain brain regions
3 Decrease blood flow in the striatum
4 Structural changes in the caudate and putamen
ADHD is a Chemical Problem
bull Dysfunction of dopaminergic and noradrenergic systems
bull Dopamine and norepinephrine are important in drugs that treat ADHD
In ADHD children the rate of glucosemetabolism in basal ganglions and in the frontal cortex is reduced
EF networks depends 1ry on 2 chemicals
Dopamine Norepinephrine
Not release and reload effectivelyMedications slow reuptake so longer in
contact with receptors
bull Methyl phenydate amp Atomoxetene
Mode of action
ndash prevents the reuptake of norepinephrine into the presynaptic neuron
X
AETIOLOGY
I AM A BUSY MOTHERor
WE ARE NOT A GOOD FAMILYor
HE IS A SPOILED BABY
1
1- Hereditary ADHD
Twin adoption
ADHD Is highly heritable
HEIGHT
ADHD
SCHIZOPHRENIA
IQ
DEPRESSION
DBH 5HTT SNAP-25
= dopamine transporter gene (DAT1)
= dopamine receptor gene (DRD)
D4
D5
= serotonin transporter gene5HTT
= others DBH HTR1Bm SNAP-25
2- Acquired Brain Injury
A prenatal Factors
CNS injury during Fetal Development
- Premature babies
-Traumainfectioncomplications
- Fetal exposure to drugs
- maternal smoking and maternal alcohol addiction
2- Acquired Brain Injury (cont)
B- CNS lesion during labour bull Type of Delivery can have impact if sudden or
extremely long and slow deliverybull Birth anoxia bull Weight at birth if SGA
C- Post Birth Factorsbull Cranial bleed bull Seizures bull Concussioncomabull Environmental chronic Lead poison
Environmental factors bull exposures to neurodevelopmental toxinstoxins
such as heavy metals and organohalide pollutants (lead mercury toxins -ldquoteratogensrdquo)
bull adverse responses to food additivesbull intolerances to foods (sugar )bull sensitivities to environmental chemicals
molds and fungi
Organochlorines and Child Development
bull Dichlorodiphenyl dichloroethylene(ppDDE) measured in umbilical cord blood
bull Serum levels were negatively associated with both mental and psychomotor development
bull The higher the serum level the worse the childs development at 13 months old
Recent studies suggest that causalpathways in some cases involve
complex interactions betweengenetic and environmental factors
2009
bull Less effective parenting - mother not in home father working more Everyone more stressed
bull Egypt educational curriculum and processbull Higher demands on childrenbull Toxins in the prenatal and early childhood environment (over
200 contaminants found in umbilical cord blood )
Why the Explosion in ADHD
MANAGEMENT
Recognition and Referral
OSHA PLAN OF MANAGEMENT
OF ADHD CHILD
Modified from AAP 2011
Recognition and Referral
Diagnosis (Assessment)
1+2+3
bull At present there is no biomedical laboratory test for ADHD
Neuropharmacology 57 (2009) 579ndash589
DD 70
DD for ADHD
bull 1- anxiety disordersbull 2- conduct disorderbull 3- oppositional defiant disorderbull 4- impulse-control or mood disordersbull 5- learning disordersbull 6- mental retardation
bull 7- gifted childrenbull 8- pervasive developmental disorders
DD for ADHD (contin)
bull 9- depression bull 10-Bipolar disorders Schizophrenia bull 11- Drugs PB CZP
bull 12- Misfits between the child and school or even the child and teacher
bull 13- substance abuse stimulants cocaine phenyclidine
bull 14- hyperthyroidismbull 15- BHL
bull
bull
Bip
ola
r D
iso
rder
Rule outs for the Diagnosis of ADHD
Myth ADHD child Can do bull Video Gamesbull Watch TVbull Computersbull Play Sportsbull Build Leggos
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
When are ADHDimpairments Noticeable
bull some preschoolbull Some middle elementary schoolbull Some college or later
Most in 1ry school
Executive Functionschallenges may reveal Weakness bull EF weakness may not noticeable until
onersquos self-management is challenged by increased demands of adult life
EEGECG
Executive FunctionsDevelopment and Demands
bull In early childhood others perform all executive functions for the child (parents sibs and other caretakers)
bull Thereafter the child should be able (or is forced to) perform these functions for self
Onset before 7
PATHOGENESIS
summarybull structural and functional imaging studies
suggest that dysfunction of cingulate frontal and parietal cortical regions and imbalances in the dopaminergic and noradrenergic systems contribute to the pathophysiology of ADHD
Imaging Studies
1 Reduction of total brain size
2 Reduction of certain brain regions
3 Decrease blood flow in the striatum
4 Structural changes in the caudate and putamen
ADHD is a Chemical Problem
bull Dysfunction of dopaminergic and noradrenergic systems
bull Dopamine and norepinephrine are important in drugs that treat ADHD
In ADHD children the rate of glucosemetabolism in basal ganglions and in the frontal cortex is reduced
EF networks depends 1ry on 2 chemicals
Dopamine Norepinephrine
Not release and reload effectivelyMedications slow reuptake so longer in
contact with receptors
bull Methyl phenydate amp Atomoxetene
Mode of action
ndash prevents the reuptake of norepinephrine into the presynaptic neuron
X
AETIOLOGY
I AM A BUSY MOTHERor
WE ARE NOT A GOOD FAMILYor
HE IS A SPOILED BABY
1
1- Hereditary ADHD
Twin adoption
ADHD Is highly heritable
HEIGHT
ADHD
SCHIZOPHRENIA
IQ
DEPRESSION
DBH 5HTT SNAP-25
= dopamine transporter gene (DAT1)
= dopamine receptor gene (DRD)
D4
D5
= serotonin transporter gene5HTT
= others DBH HTR1Bm SNAP-25
2- Acquired Brain Injury
A prenatal Factors
CNS injury during Fetal Development
- Premature babies
-Traumainfectioncomplications
- Fetal exposure to drugs
- maternal smoking and maternal alcohol addiction
2- Acquired Brain Injury (cont)
B- CNS lesion during labour bull Type of Delivery can have impact if sudden or
extremely long and slow deliverybull Birth anoxia bull Weight at birth if SGA
C- Post Birth Factorsbull Cranial bleed bull Seizures bull Concussioncomabull Environmental chronic Lead poison
Environmental factors bull exposures to neurodevelopmental toxinstoxins
such as heavy metals and organohalide pollutants (lead mercury toxins -ldquoteratogensrdquo)
bull adverse responses to food additivesbull intolerances to foods (sugar )bull sensitivities to environmental chemicals
molds and fungi
Organochlorines and Child Development
bull Dichlorodiphenyl dichloroethylene(ppDDE) measured in umbilical cord blood
bull Serum levels were negatively associated with both mental and psychomotor development
bull The higher the serum level the worse the childs development at 13 months old
Recent studies suggest that causalpathways in some cases involve
complex interactions betweengenetic and environmental factors
2009
bull Less effective parenting - mother not in home father working more Everyone more stressed
bull Egypt educational curriculum and processbull Higher demands on childrenbull Toxins in the prenatal and early childhood environment (over
200 contaminants found in umbilical cord blood )
Why the Explosion in ADHD
MANAGEMENT
Recognition and Referral
OSHA PLAN OF MANAGEMENT
OF ADHD CHILD
Modified from AAP 2011
Recognition and Referral
Diagnosis (Assessment)
1+2+3
bull At present there is no biomedical laboratory test for ADHD
Neuropharmacology 57 (2009) 579ndash589
DD 70
DD for ADHD
bull 1- anxiety disordersbull 2- conduct disorderbull 3- oppositional defiant disorderbull 4- impulse-control or mood disordersbull 5- learning disordersbull 6- mental retardation
bull 7- gifted childrenbull 8- pervasive developmental disorders
DD for ADHD (contin)
bull 9- depression bull 10-Bipolar disorders Schizophrenia bull 11- Drugs PB CZP
bull 12- Misfits between the child and school or even the child and teacher
bull 13- substance abuse stimulants cocaine phenyclidine
bull 14- hyperthyroidismbull 15- BHL
bull
bull
Bip
ola
r D
iso
rder
Rule outs for the Diagnosis of ADHD
Myth ADHD child Can do bull Video Gamesbull Watch TVbull Computersbull Play Sportsbull Build Leggos
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
Executive Functionschallenges may reveal Weakness bull EF weakness may not noticeable until
onersquos self-management is challenged by increased demands of adult life
EEGECG
Executive FunctionsDevelopment and Demands
bull In early childhood others perform all executive functions for the child (parents sibs and other caretakers)
bull Thereafter the child should be able (or is forced to) perform these functions for self
Onset before 7
PATHOGENESIS
summarybull structural and functional imaging studies
suggest that dysfunction of cingulate frontal and parietal cortical regions and imbalances in the dopaminergic and noradrenergic systems contribute to the pathophysiology of ADHD
Imaging Studies
1 Reduction of total brain size
2 Reduction of certain brain regions
3 Decrease blood flow in the striatum
4 Structural changes in the caudate and putamen
ADHD is a Chemical Problem
bull Dysfunction of dopaminergic and noradrenergic systems
bull Dopamine and norepinephrine are important in drugs that treat ADHD
In ADHD children the rate of glucosemetabolism in basal ganglions and in the frontal cortex is reduced
EF networks depends 1ry on 2 chemicals
Dopamine Norepinephrine
Not release and reload effectivelyMedications slow reuptake so longer in
contact with receptors
bull Methyl phenydate amp Atomoxetene
Mode of action
ndash prevents the reuptake of norepinephrine into the presynaptic neuron
X
AETIOLOGY
I AM A BUSY MOTHERor
WE ARE NOT A GOOD FAMILYor
HE IS A SPOILED BABY
1
1- Hereditary ADHD
Twin adoption
ADHD Is highly heritable
HEIGHT
ADHD
SCHIZOPHRENIA
IQ
DEPRESSION
DBH 5HTT SNAP-25
= dopamine transporter gene (DAT1)
= dopamine receptor gene (DRD)
D4
D5
= serotonin transporter gene5HTT
= others DBH HTR1Bm SNAP-25
2- Acquired Brain Injury
A prenatal Factors
CNS injury during Fetal Development
- Premature babies
-Traumainfectioncomplications
- Fetal exposure to drugs
- maternal smoking and maternal alcohol addiction
2- Acquired Brain Injury (cont)
B- CNS lesion during labour bull Type of Delivery can have impact if sudden or
extremely long and slow deliverybull Birth anoxia bull Weight at birth if SGA
C- Post Birth Factorsbull Cranial bleed bull Seizures bull Concussioncomabull Environmental chronic Lead poison
Environmental factors bull exposures to neurodevelopmental toxinstoxins
such as heavy metals and organohalide pollutants (lead mercury toxins -ldquoteratogensrdquo)
bull adverse responses to food additivesbull intolerances to foods (sugar )bull sensitivities to environmental chemicals
molds and fungi
Organochlorines and Child Development
bull Dichlorodiphenyl dichloroethylene(ppDDE) measured in umbilical cord blood
bull Serum levels were negatively associated with both mental and psychomotor development
bull The higher the serum level the worse the childs development at 13 months old
Recent studies suggest that causalpathways in some cases involve
complex interactions betweengenetic and environmental factors
2009
bull Less effective parenting - mother not in home father working more Everyone more stressed
bull Egypt educational curriculum and processbull Higher demands on childrenbull Toxins in the prenatal and early childhood environment (over
200 contaminants found in umbilical cord blood )
Why the Explosion in ADHD
MANAGEMENT
Recognition and Referral
OSHA PLAN OF MANAGEMENT
OF ADHD CHILD
Modified from AAP 2011
Recognition and Referral
Diagnosis (Assessment)
1+2+3
bull At present there is no biomedical laboratory test for ADHD
Neuropharmacology 57 (2009) 579ndash589
DD 70
DD for ADHD
bull 1- anxiety disordersbull 2- conduct disorderbull 3- oppositional defiant disorderbull 4- impulse-control or mood disordersbull 5- learning disordersbull 6- mental retardation
bull 7- gifted childrenbull 8- pervasive developmental disorders
DD for ADHD (contin)
bull 9- depression bull 10-Bipolar disorders Schizophrenia bull 11- Drugs PB CZP
bull 12- Misfits between the child and school or even the child and teacher
bull 13- substance abuse stimulants cocaine phenyclidine
bull 14- hyperthyroidismbull 15- BHL
bull
bull
Bip
ola
r D
iso
rder
Rule outs for the Diagnosis of ADHD
Myth ADHD child Can do bull Video Gamesbull Watch TVbull Computersbull Play Sportsbull Build Leggos
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
Executive FunctionsDevelopment and Demands
bull In early childhood others perform all executive functions for the child (parents sibs and other caretakers)
bull Thereafter the child should be able (or is forced to) perform these functions for self
Onset before 7
PATHOGENESIS
summarybull structural and functional imaging studies
suggest that dysfunction of cingulate frontal and parietal cortical regions and imbalances in the dopaminergic and noradrenergic systems contribute to the pathophysiology of ADHD
Imaging Studies
1 Reduction of total brain size
2 Reduction of certain brain regions
3 Decrease blood flow in the striatum
4 Structural changes in the caudate and putamen
ADHD is a Chemical Problem
bull Dysfunction of dopaminergic and noradrenergic systems
bull Dopamine and norepinephrine are important in drugs that treat ADHD
In ADHD children the rate of glucosemetabolism in basal ganglions and in the frontal cortex is reduced
EF networks depends 1ry on 2 chemicals
Dopamine Norepinephrine
Not release and reload effectivelyMedications slow reuptake so longer in
contact with receptors
bull Methyl phenydate amp Atomoxetene
Mode of action
ndash prevents the reuptake of norepinephrine into the presynaptic neuron
X
AETIOLOGY
I AM A BUSY MOTHERor
WE ARE NOT A GOOD FAMILYor
HE IS A SPOILED BABY
1
1- Hereditary ADHD
Twin adoption
ADHD Is highly heritable
HEIGHT
ADHD
SCHIZOPHRENIA
IQ
DEPRESSION
DBH 5HTT SNAP-25
= dopamine transporter gene (DAT1)
= dopamine receptor gene (DRD)
D4
D5
= serotonin transporter gene5HTT
= others DBH HTR1Bm SNAP-25
2- Acquired Brain Injury
A prenatal Factors
CNS injury during Fetal Development
- Premature babies
-Traumainfectioncomplications
- Fetal exposure to drugs
- maternal smoking and maternal alcohol addiction
2- Acquired Brain Injury (cont)
B- CNS lesion during labour bull Type of Delivery can have impact if sudden or
extremely long and slow deliverybull Birth anoxia bull Weight at birth if SGA
C- Post Birth Factorsbull Cranial bleed bull Seizures bull Concussioncomabull Environmental chronic Lead poison
Environmental factors bull exposures to neurodevelopmental toxinstoxins
such as heavy metals and organohalide pollutants (lead mercury toxins -ldquoteratogensrdquo)
bull adverse responses to food additivesbull intolerances to foods (sugar )bull sensitivities to environmental chemicals
molds and fungi
Organochlorines and Child Development
bull Dichlorodiphenyl dichloroethylene(ppDDE) measured in umbilical cord blood
bull Serum levels were negatively associated with both mental and psychomotor development
bull The higher the serum level the worse the childs development at 13 months old
Recent studies suggest that causalpathways in some cases involve
complex interactions betweengenetic and environmental factors
2009
bull Less effective parenting - mother not in home father working more Everyone more stressed
bull Egypt educational curriculum and processbull Higher demands on childrenbull Toxins in the prenatal and early childhood environment (over
200 contaminants found in umbilical cord blood )
Why the Explosion in ADHD
MANAGEMENT
Recognition and Referral
OSHA PLAN OF MANAGEMENT
OF ADHD CHILD
Modified from AAP 2011
Recognition and Referral
Diagnosis (Assessment)
1+2+3
bull At present there is no biomedical laboratory test for ADHD
Neuropharmacology 57 (2009) 579ndash589
DD 70
DD for ADHD
bull 1- anxiety disordersbull 2- conduct disorderbull 3- oppositional defiant disorderbull 4- impulse-control or mood disordersbull 5- learning disordersbull 6- mental retardation
bull 7- gifted childrenbull 8- pervasive developmental disorders
DD for ADHD (contin)
bull 9- depression bull 10-Bipolar disorders Schizophrenia bull 11- Drugs PB CZP
bull 12- Misfits between the child and school or even the child and teacher
bull 13- substance abuse stimulants cocaine phenyclidine
bull 14- hyperthyroidismbull 15- BHL
bull
bull
Bip
ola
r D
iso
rder
Rule outs for the Diagnosis of ADHD
Myth ADHD child Can do bull Video Gamesbull Watch TVbull Computersbull Play Sportsbull Build Leggos
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
PATHOGENESIS
summarybull structural and functional imaging studies
suggest that dysfunction of cingulate frontal and parietal cortical regions and imbalances in the dopaminergic and noradrenergic systems contribute to the pathophysiology of ADHD
Imaging Studies
1 Reduction of total brain size
2 Reduction of certain brain regions
3 Decrease blood flow in the striatum
4 Structural changes in the caudate and putamen
ADHD is a Chemical Problem
bull Dysfunction of dopaminergic and noradrenergic systems
bull Dopamine and norepinephrine are important in drugs that treat ADHD
In ADHD children the rate of glucosemetabolism in basal ganglions and in the frontal cortex is reduced
EF networks depends 1ry on 2 chemicals
Dopamine Norepinephrine
Not release and reload effectivelyMedications slow reuptake so longer in
contact with receptors
bull Methyl phenydate amp Atomoxetene
Mode of action
ndash prevents the reuptake of norepinephrine into the presynaptic neuron
X
AETIOLOGY
I AM A BUSY MOTHERor
WE ARE NOT A GOOD FAMILYor
HE IS A SPOILED BABY
1
1- Hereditary ADHD
Twin adoption
ADHD Is highly heritable
HEIGHT
ADHD
SCHIZOPHRENIA
IQ
DEPRESSION
DBH 5HTT SNAP-25
= dopamine transporter gene (DAT1)
= dopamine receptor gene (DRD)
D4
D5
= serotonin transporter gene5HTT
= others DBH HTR1Bm SNAP-25
2- Acquired Brain Injury
A prenatal Factors
CNS injury during Fetal Development
- Premature babies
-Traumainfectioncomplications
- Fetal exposure to drugs
- maternal smoking and maternal alcohol addiction
2- Acquired Brain Injury (cont)
B- CNS lesion during labour bull Type of Delivery can have impact if sudden or
extremely long and slow deliverybull Birth anoxia bull Weight at birth if SGA
C- Post Birth Factorsbull Cranial bleed bull Seizures bull Concussioncomabull Environmental chronic Lead poison
Environmental factors bull exposures to neurodevelopmental toxinstoxins
such as heavy metals and organohalide pollutants (lead mercury toxins -ldquoteratogensrdquo)
bull adverse responses to food additivesbull intolerances to foods (sugar )bull sensitivities to environmental chemicals
molds and fungi
Organochlorines and Child Development
bull Dichlorodiphenyl dichloroethylene(ppDDE) measured in umbilical cord blood
bull Serum levels were negatively associated with both mental and psychomotor development
bull The higher the serum level the worse the childs development at 13 months old
Recent studies suggest that causalpathways in some cases involve
complex interactions betweengenetic and environmental factors
2009
bull Less effective parenting - mother not in home father working more Everyone more stressed
bull Egypt educational curriculum and processbull Higher demands on childrenbull Toxins in the prenatal and early childhood environment (over
200 contaminants found in umbilical cord blood )
Why the Explosion in ADHD
MANAGEMENT
Recognition and Referral
OSHA PLAN OF MANAGEMENT
OF ADHD CHILD
Modified from AAP 2011
Recognition and Referral
Diagnosis (Assessment)
1+2+3
bull At present there is no biomedical laboratory test for ADHD
Neuropharmacology 57 (2009) 579ndash589
DD 70
DD for ADHD
bull 1- anxiety disordersbull 2- conduct disorderbull 3- oppositional defiant disorderbull 4- impulse-control or mood disordersbull 5- learning disordersbull 6- mental retardation
bull 7- gifted childrenbull 8- pervasive developmental disorders
DD for ADHD (contin)
bull 9- depression bull 10-Bipolar disorders Schizophrenia bull 11- Drugs PB CZP
bull 12- Misfits between the child and school or even the child and teacher
bull 13- substance abuse stimulants cocaine phenyclidine
bull 14- hyperthyroidismbull 15- BHL
bull
bull
Bip
ola
r D
iso
rder
Rule outs for the Diagnosis of ADHD
Myth ADHD child Can do bull Video Gamesbull Watch TVbull Computersbull Play Sportsbull Build Leggos
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
summarybull structural and functional imaging studies
suggest that dysfunction of cingulate frontal and parietal cortical regions and imbalances in the dopaminergic and noradrenergic systems contribute to the pathophysiology of ADHD
Imaging Studies
1 Reduction of total brain size
2 Reduction of certain brain regions
3 Decrease blood flow in the striatum
4 Structural changes in the caudate and putamen
ADHD is a Chemical Problem
bull Dysfunction of dopaminergic and noradrenergic systems
bull Dopamine and norepinephrine are important in drugs that treat ADHD
In ADHD children the rate of glucosemetabolism in basal ganglions and in the frontal cortex is reduced
EF networks depends 1ry on 2 chemicals
Dopamine Norepinephrine
Not release and reload effectivelyMedications slow reuptake so longer in
contact with receptors
bull Methyl phenydate amp Atomoxetene
Mode of action
ndash prevents the reuptake of norepinephrine into the presynaptic neuron
X
AETIOLOGY
I AM A BUSY MOTHERor
WE ARE NOT A GOOD FAMILYor
HE IS A SPOILED BABY
1
1- Hereditary ADHD
Twin adoption
ADHD Is highly heritable
HEIGHT
ADHD
SCHIZOPHRENIA
IQ
DEPRESSION
DBH 5HTT SNAP-25
= dopamine transporter gene (DAT1)
= dopamine receptor gene (DRD)
D4
D5
= serotonin transporter gene5HTT
= others DBH HTR1Bm SNAP-25
2- Acquired Brain Injury
A prenatal Factors
CNS injury during Fetal Development
- Premature babies
-Traumainfectioncomplications
- Fetal exposure to drugs
- maternal smoking and maternal alcohol addiction
2- Acquired Brain Injury (cont)
B- CNS lesion during labour bull Type of Delivery can have impact if sudden or
extremely long and slow deliverybull Birth anoxia bull Weight at birth if SGA
C- Post Birth Factorsbull Cranial bleed bull Seizures bull Concussioncomabull Environmental chronic Lead poison
Environmental factors bull exposures to neurodevelopmental toxinstoxins
such as heavy metals and organohalide pollutants (lead mercury toxins -ldquoteratogensrdquo)
bull adverse responses to food additivesbull intolerances to foods (sugar )bull sensitivities to environmental chemicals
molds and fungi
Organochlorines and Child Development
bull Dichlorodiphenyl dichloroethylene(ppDDE) measured in umbilical cord blood
bull Serum levels were negatively associated with both mental and psychomotor development
bull The higher the serum level the worse the childs development at 13 months old
Recent studies suggest that causalpathways in some cases involve
complex interactions betweengenetic and environmental factors
2009
bull Less effective parenting - mother not in home father working more Everyone more stressed
bull Egypt educational curriculum and processbull Higher demands on childrenbull Toxins in the prenatal and early childhood environment (over
200 contaminants found in umbilical cord blood )
Why the Explosion in ADHD
MANAGEMENT
Recognition and Referral
OSHA PLAN OF MANAGEMENT
OF ADHD CHILD
Modified from AAP 2011
Recognition and Referral
Diagnosis (Assessment)
1+2+3
bull At present there is no biomedical laboratory test for ADHD
Neuropharmacology 57 (2009) 579ndash589
DD 70
DD for ADHD
bull 1- anxiety disordersbull 2- conduct disorderbull 3- oppositional defiant disorderbull 4- impulse-control or mood disordersbull 5- learning disordersbull 6- mental retardation
bull 7- gifted childrenbull 8- pervasive developmental disorders
DD for ADHD (contin)
bull 9- depression bull 10-Bipolar disorders Schizophrenia bull 11- Drugs PB CZP
bull 12- Misfits between the child and school or even the child and teacher
bull 13- substance abuse stimulants cocaine phenyclidine
bull 14- hyperthyroidismbull 15- BHL
bull
bull
Bip
ola
r D
iso
rder
Rule outs for the Diagnosis of ADHD
Myth ADHD child Can do bull Video Gamesbull Watch TVbull Computersbull Play Sportsbull Build Leggos
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
Imaging Studies
1 Reduction of total brain size
2 Reduction of certain brain regions
3 Decrease blood flow in the striatum
4 Structural changes in the caudate and putamen
ADHD is a Chemical Problem
bull Dysfunction of dopaminergic and noradrenergic systems
bull Dopamine and norepinephrine are important in drugs that treat ADHD
In ADHD children the rate of glucosemetabolism in basal ganglions and in the frontal cortex is reduced
EF networks depends 1ry on 2 chemicals
Dopamine Norepinephrine
Not release and reload effectivelyMedications slow reuptake so longer in
contact with receptors
bull Methyl phenydate amp Atomoxetene
Mode of action
ndash prevents the reuptake of norepinephrine into the presynaptic neuron
X
AETIOLOGY
I AM A BUSY MOTHERor
WE ARE NOT A GOOD FAMILYor
HE IS A SPOILED BABY
1
1- Hereditary ADHD
Twin adoption
ADHD Is highly heritable
HEIGHT
ADHD
SCHIZOPHRENIA
IQ
DEPRESSION
DBH 5HTT SNAP-25
= dopamine transporter gene (DAT1)
= dopamine receptor gene (DRD)
D4
D5
= serotonin transporter gene5HTT
= others DBH HTR1Bm SNAP-25
2- Acquired Brain Injury
A prenatal Factors
CNS injury during Fetal Development
- Premature babies
-Traumainfectioncomplications
- Fetal exposure to drugs
- maternal smoking and maternal alcohol addiction
2- Acquired Brain Injury (cont)
B- CNS lesion during labour bull Type of Delivery can have impact if sudden or
extremely long and slow deliverybull Birth anoxia bull Weight at birth if SGA
C- Post Birth Factorsbull Cranial bleed bull Seizures bull Concussioncomabull Environmental chronic Lead poison
Environmental factors bull exposures to neurodevelopmental toxinstoxins
such as heavy metals and organohalide pollutants (lead mercury toxins -ldquoteratogensrdquo)
bull adverse responses to food additivesbull intolerances to foods (sugar )bull sensitivities to environmental chemicals
molds and fungi
Organochlorines and Child Development
bull Dichlorodiphenyl dichloroethylene(ppDDE) measured in umbilical cord blood
bull Serum levels were negatively associated with both mental and psychomotor development
bull The higher the serum level the worse the childs development at 13 months old
Recent studies suggest that causalpathways in some cases involve
complex interactions betweengenetic and environmental factors
2009
bull Less effective parenting - mother not in home father working more Everyone more stressed
bull Egypt educational curriculum and processbull Higher demands on childrenbull Toxins in the prenatal and early childhood environment (over
200 contaminants found in umbilical cord blood )
Why the Explosion in ADHD
MANAGEMENT
Recognition and Referral
OSHA PLAN OF MANAGEMENT
OF ADHD CHILD
Modified from AAP 2011
Recognition and Referral
Diagnosis (Assessment)
1+2+3
bull At present there is no biomedical laboratory test for ADHD
Neuropharmacology 57 (2009) 579ndash589
DD 70
DD for ADHD
bull 1- anxiety disordersbull 2- conduct disorderbull 3- oppositional defiant disorderbull 4- impulse-control or mood disordersbull 5- learning disordersbull 6- mental retardation
bull 7- gifted childrenbull 8- pervasive developmental disorders
DD for ADHD (contin)
bull 9- depression bull 10-Bipolar disorders Schizophrenia bull 11- Drugs PB CZP
bull 12- Misfits between the child and school or even the child and teacher
bull 13- substance abuse stimulants cocaine phenyclidine
bull 14- hyperthyroidismbull 15- BHL
bull
bull
Bip
ola
r D
iso
rder
Rule outs for the Diagnosis of ADHD
Myth ADHD child Can do bull Video Gamesbull Watch TVbull Computersbull Play Sportsbull Build Leggos
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
ADHD is a Chemical Problem
bull Dysfunction of dopaminergic and noradrenergic systems
bull Dopamine and norepinephrine are important in drugs that treat ADHD
In ADHD children the rate of glucosemetabolism in basal ganglions and in the frontal cortex is reduced
EF networks depends 1ry on 2 chemicals
Dopamine Norepinephrine
Not release and reload effectivelyMedications slow reuptake so longer in
contact with receptors
bull Methyl phenydate amp Atomoxetene
Mode of action
ndash prevents the reuptake of norepinephrine into the presynaptic neuron
X
AETIOLOGY
I AM A BUSY MOTHERor
WE ARE NOT A GOOD FAMILYor
HE IS A SPOILED BABY
1
1- Hereditary ADHD
Twin adoption
ADHD Is highly heritable
HEIGHT
ADHD
SCHIZOPHRENIA
IQ
DEPRESSION
DBH 5HTT SNAP-25
= dopamine transporter gene (DAT1)
= dopamine receptor gene (DRD)
D4
D5
= serotonin transporter gene5HTT
= others DBH HTR1Bm SNAP-25
2- Acquired Brain Injury
A prenatal Factors
CNS injury during Fetal Development
- Premature babies
-Traumainfectioncomplications
- Fetal exposure to drugs
- maternal smoking and maternal alcohol addiction
2- Acquired Brain Injury (cont)
B- CNS lesion during labour bull Type of Delivery can have impact if sudden or
extremely long and slow deliverybull Birth anoxia bull Weight at birth if SGA
C- Post Birth Factorsbull Cranial bleed bull Seizures bull Concussioncomabull Environmental chronic Lead poison
Environmental factors bull exposures to neurodevelopmental toxinstoxins
such as heavy metals and organohalide pollutants (lead mercury toxins -ldquoteratogensrdquo)
bull adverse responses to food additivesbull intolerances to foods (sugar )bull sensitivities to environmental chemicals
molds and fungi
Organochlorines and Child Development
bull Dichlorodiphenyl dichloroethylene(ppDDE) measured in umbilical cord blood
bull Serum levels were negatively associated with both mental and psychomotor development
bull The higher the serum level the worse the childs development at 13 months old
Recent studies suggest that causalpathways in some cases involve
complex interactions betweengenetic and environmental factors
2009
bull Less effective parenting - mother not in home father working more Everyone more stressed
bull Egypt educational curriculum and processbull Higher demands on childrenbull Toxins in the prenatal and early childhood environment (over
200 contaminants found in umbilical cord blood )
Why the Explosion in ADHD
MANAGEMENT
Recognition and Referral
OSHA PLAN OF MANAGEMENT
OF ADHD CHILD
Modified from AAP 2011
Recognition and Referral
Diagnosis (Assessment)
1+2+3
bull At present there is no biomedical laboratory test for ADHD
Neuropharmacology 57 (2009) 579ndash589
DD 70
DD for ADHD
bull 1- anxiety disordersbull 2- conduct disorderbull 3- oppositional defiant disorderbull 4- impulse-control or mood disordersbull 5- learning disordersbull 6- mental retardation
bull 7- gifted childrenbull 8- pervasive developmental disorders
DD for ADHD (contin)
bull 9- depression bull 10-Bipolar disorders Schizophrenia bull 11- Drugs PB CZP
bull 12- Misfits between the child and school or even the child and teacher
bull 13- substance abuse stimulants cocaine phenyclidine
bull 14- hyperthyroidismbull 15- BHL
bull
bull
Bip
ola
r D
iso
rder
Rule outs for the Diagnosis of ADHD
Myth ADHD child Can do bull Video Gamesbull Watch TVbull Computersbull Play Sportsbull Build Leggos
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
EF networks depends 1ry on 2 chemicals
Dopamine Norepinephrine
Not release and reload effectivelyMedications slow reuptake so longer in
contact with receptors
bull Methyl phenydate amp Atomoxetene
Mode of action
ndash prevents the reuptake of norepinephrine into the presynaptic neuron
X
AETIOLOGY
I AM A BUSY MOTHERor
WE ARE NOT A GOOD FAMILYor
HE IS A SPOILED BABY
1
1- Hereditary ADHD
Twin adoption
ADHD Is highly heritable
HEIGHT
ADHD
SCHIZOPHRENIA
IQ
DEPRESSION
DBH 5HTT SNAP-25
= dopamine transporter gene (DAT1)
= dopamine receptor gene (DRD)
D4
D5
= serotonin transporter gene5HTT
= others DBH HTR1Bm SNAP-25
2- Acquired Brain Injury
A prenatal Factors
CNS injury during Fetal Development
- Premature babies
-Traumainfectioncomplications
- Fetal exposure to drugs
- maternal smoking and maternal alcohol addiction
2- Acquired Brain Injury (cont)
B- CNS lesion during labour bull Type of Delivery can have impact if sudden or
extremely long and slow deliverybull Birth anoxia bull Weight at birth if SGA
C- Post Birth Factorsbull Cranial bleed bull Seizures bull Concussioncomabull Environmental chronic Lead poison
Environmental factors bull exposures to neurodevelopmental toxinstoxins
such as heavy metals and organohalide pollutants (lead mercury toxins -ldquoteratogensrdquo)
bull adverse responses to food additivesbull intolerances to foods (sugar )bull sensitivities to environmental chemicals
molds and fungi
Organochlorines and Child Development
bull Dichlorodiphenyl dichloroethylene(ppDDE) measured in umbilical cord blood
bull Serum levels were negatively associated with both mental and psychomotor development
bull The higher the serum level the worse the childs development at 13 months old
Recent studies suggest that causalpathways in some cases involve
complex interactions betweengenetic and environmental factors
2009
bull Less effective parenting - mother not in home father working more Everyone more stressed
bull Egypt educational curriculum and processbull Higher demands on childrenbull Toxins in the prenatal and early childhood environment (over
200 contaminants found in umbilical cord blood )
Why the Explosion in ADHD
MANAGEMENT
Recognition and Referral
OSHA PLAN OF MANAGEMENT
OF ADHD CHILD
Modified from AAP 2011
Recognition and Referral
Diagnosis (Assessment)
1+2+3
bull At present there is no biomedical laboratory test for ADHD
Neuropharmacology 57 (2009) 579ndash589
DD 70
DD for ADHD
bull 1- anxiety disordersbull 2- conduct disorderbull 3- oppositional defiant disorderbull 4- impulse-control or mood disordersbull 5- learning disordersbull 6- mental retardation
bull 7- gifted childrenbull 8- pervasive developmental disorders
DD for ADHD (contin)
bull 9- depression bull 10-Bipolar disorders Schizophrenia bull 11- Drugs PB CZP
bull 12- Misfits between the child and school or even the child and teacher
bull 13- substance abuse stimulants cocaine phenyclidine
bull 14- hyperthyroidismbull 15- BHL
bull
bull
Bip
ola
r D
iso
rder
Rule outs for the Diagnosis of ADHD
Myth ADHD child Can do bull Video Gamesbull Watch TVbull Computersbull Play Sportsbull Build Leggos
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
bull Methyl phenydate amp Atomoxetene
Mode of action
ndash prevents the reuptake of norepinephrine into the presynaptic neuron
X
AETIOLOGY
I AM A BUSY MOTHERor
WE ARE NOT A GOOD FAMILYor
HE IS A SPOILED BABY
1
1- Hereditary ADHD
Twin adoption
ADHD Is highly heritable
HEIGHT
ADHD
SCHIZOPHRENIA
IQ
DEPRESSION
DBH 5HTT SNAP-25
= dopamine transporter gene (DAT1)
= dopamine receptor gene (DRD)
D4
D5
= serotonin transporter gene5HTT
= others DBH HTR1Bm SNAP-25
2- Acquired Brain Injury
A prenatal Factors
CNS injury during Fetal Development
- Premature babies
-Traumainfectioncomplications
- Fetal exposure to drugs
- maternal smoking and maternal alcohol addiction
2- Acquired Brain Injury (cont)
B- CNS lesion during labour bull Type of Delivery can have impact if sudden or
extremely long and slow deliverybull Birth anoxia bull Weight at birth if SGA
C- Post Birth Factorsbull Cranial bleed bull Seizures bull Concussioncomabull Environmental chronic Lead poison
Environmental factors bull exposures to neurodevelopmental toxinstoxins
such as heavy metals and organohalide pollutants (lead mercury toxins -ldquoteratogensrdquo)
bull adverse responses to food additivesbull intolerances to foods (sugar )bull sensitivities to environmental chemicals
molds and fungi
Organochlorines and Child Development
bull Dichlorodiphenyl dichloroethylene(ppDDE) measured in umbilical cord blood
bull Serum levels were negatively associated with both mental and psychomotor development
bull The higher the serum level the worse the childs development at 13 months old
Recent studies suggest that causalpathways in some cases involve
complex interactions betweengenetic and environmental factors
2009
bull Less effective parenting - mother not in home father working more Everyone more stressed
bull Egypt educational curriculum and processbull Higher demands on childrenbull Toxins in the prenatal and early childhood environment (over
200 contaminants found in umbilical cord blood )
Why the Explosion in ADHD
MANAGEMENT
Recognition and Referral
OSHA PLAN OF MANAGEMENT
OF ADHD CHILD
Modified from AAP 2011
Recognition and Referral
Diagnosis (Assessment)
1+2+3
bull At present there is no biomedical laboratory test for ADHD
Neuropharmacology 57 (2009) 579ndash589
DD 70
DD for ADHD
bull 1- anxiety disordersbull 2- conduct disorderbull 3- oppositional defiant disorderbull 4- impulse-control or mood disordersbull 5- learning disordersbull 6- mental retardation
bull 7- gifted childrenbull 8- pervasive developmental disorders
DD for ADHD (contin)
bull 9- depression bull 10-Bipolar disorders Schizophrenia bull 11- Drugs PB CZP
bull 12- Misfits between the child and school or even the child and teacher
bull 13- substance abuse stimulants cocaine phenyclidine
bull 14- hyperthyroidismbull 15- BHL
bull
bull
Bip
ola
r D
iso
rder
Rule outs for the Diagnosis of ADHD
Myth ADHD child Can do bull Video Gamesbull Watch TVbull Computersbull Play Sportsbull Build Leggos
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
AETIOLOGY
I AM A BUSY MOTHERor
WE ARE NOT A GOOD FAMILYor
HE IS A SPOILED BABY
1
1- Hereditary ADHD
Twin adoption
ADHD Is highly heritable
HEIGHT
ADHD
SCHIZOPHRENIA
IQ
DEPRESSION
DBH 5HTT SNAP-25
= dopamine transporter gene (DAT1)
= dopamine receptor gene (DRD)
D4
D5
= serotonin transporter gene5HTT
= others DBH HTR1Bm SNAP-25
2- Acquired Brain Injury
A prenatal Factors
CNS injury during Fetal Development
- Premature babies
-Traumainfectioncomplications
- Fetal exposure to drugs
- maternal smoking and maternal alcohol addiction
2- Acquired Brain Injury (cont)
B- CNS lesion during labour bull Type of Delivery can have impact if sudden or
extremely long and slow deliverybull Birth anoxia bull Weight at birth if SGA
C- Post Birth Factorsbull Cranial bleed bull Seizures bull Concussioncomabull Environmental chronic Lead poison
Environmental factors bull exposures to neurodevelopmental toxinstoxins
such as heavy metals and organohalide pollutants (lead mercury toxins -ldquoteratogensrdquo)
bull adverse responses to food additivesbull intolerances to foods (sugar )bull sensitivities to environmental chemicals
molds and fungi
Organochlorines and Child Development
bull Dichlorodiphenyl dichloroethylene(ppDDE) measured in umbilical cord blood
bull Serum levels were negatively associated with both mental and psychomotor development
bull The higher the serum level the worse the childs development at 13 months old
Recent studies suggest that causalpathways in some cases involve
complex interactions betweengenetic and environmental factors
2009
bull Less effective parenting - mother not in home father working more Everyone more stressed
bull Egypt educational curriculum and processbull Higher demands on childrenbull Toxins in the prenatal and early childhood environment (over
200 contaminants found in umbilical cord blood )
Why the Explosion in ADHD
MANAGEMENT
Recognition and Referral
OSHA PLAN OF MANAGEMENT
OF ADHD CHILD
Modified from AAP 2011
Recognition and Referral
Diagnosis (Assessment)
1+2+3
bull At present there is no biomedical laboratory test for ADHD
Neuropharmacology 57 (2009) 579ndash589
DD 70
DD for ADHD
bull 1- anxiety disordersbull 2- conduct disorderbull 3- oppositional defiant disorderbull 4- impulse-control or mood disordersbull 5- learning disordersbull 6- mental retardation
bull 7- gifted childrenbull 8- pervasive developmental disorders
DD for ADHD (contin)
bull 9- depression bull 10-Bipolar disorders Schizophrenia bull 11- Drugs PB CZP
bull 12- Misfits between the child and school or even the child and teacher
bull 13- substance abuse stimulants cocaine phenyclidine
bull 14- hyperthyroidismbull 15- BHL
bull
bull
Bip
ola
r D
iso
rder
Rule outs for the Diagnosis of ADHD
Myth ADHD child Can do bull Video Gamesbull Watch TVbull Computersbull Play Sportsbull Build Leggos
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
I AM A BUSY MOTHERor
WE ARE NOT A GOOD FAMILYor
HE IS A SPOILED BABY
1
1- Hereditary ADHD
Twin adoption
ADHD Is highly heritable
HEIGHT
ADHD
SCHIZOPHRENIA
IQ
DEPRESSION
DBH 5HTT SNAP-25
= dopamine transporter gene (DAT1)
= dopamine receptor gene (DRD)
D4
D5
= serotonin transporter gene5HTT
= others DBH HTR1Bm SNAP-25
2- Acquired Brain Injury
A prenatal Factors
CNS injury during Fetal Development
- Premature babies
-Traumainfectioncomplications
- Fetal exposure to drugs
- maternal smoking and maternal alcohol addiction
2- Acquired Brain Injury (cont)
B- CNS lesion during labour bull Type of Delivery can have impact if sudden or
extremely long and slow deliverybull Birth anoxia bull Weight at birth if SGA
C- Post Birth Factorsbull Cranial bleed bull Seizures bull Concussioncomabull Environmental chronic Lead poison
Environmental factors bull exposures to neurodevelopmental toxinstoxins
such as heavy metals and organohalide pollutants (lead mercury toxins -ldquoteratogensrdquo)
bull adverse responses to food additivesbull intolerances to foods (sugar )bull sensitivities to environmental chemicals
molds and fungi
Organochlorines and Child Development
bull Dichlorodiphenyl dichloroethylene(ppDDE) measured in umbilical cord blood
bull Serum levels were negatively associated with both mental and psychomotor development
bull The higher the serum level the worse the childs development at 13 months old
Recent studies suggest that causalpathways in some cases involve
complex interactions betweengenetic and environmental factors
2009
bull Less effective parenting - mother not in home father working more Everyone more stressed
bull Egypt educational curriculum and processbull Higher demands on childrenbull Toxins in the prenatal and early childhood environment (over
200 contaminants found in umbilical cord blood )
Why the Explosion in ADHD
MANAGEMENT
Recognition and Referral
OSHA PLAN OF MANAGEMENT
OF ADHD CHILD
Modified from AAP 2011
Recognition and Referral
Diagnosis (Assessment)
1+2+3
bull At present there is no biomedical laboratory test for ADHD
Neuropharmacology 57 (2009) 579ndash589
DD 70
DD for ADHD
bull 1- anxiety disordersbull 2- conduct disorderbull 3- oppositional defiant disorderbull 4- impulse-control or mood disordersbull 5- learning disordersbull 6- mental retardation
bull 7- gifted childrenbull 8- pervasive developmental disorders
DD for ADHD (contin)
bull 9- depression bull 10-Bipolar disorders Schizophrenia bull 11- Drugs PB CZP
bull 12- Misfits between the child and school or even the child and teacher
bull 13- substance abuse stimulants cocaine phenyclidine
bull 14- hyperthyroidismbull 15- BHL
bull
bull
Bip
ola
r D
iso
rder
Rule outs for the Diagnosis of ADHD
Myth ADHD child Can do bull Video Gamesbull Watch TVbull Computersbull Play Sportsbull Build Leggos
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
1
1- Hereditary ADHD
Twin adoption
ADHD Is highly heritable
HEIGHT
ADHD
SCHIZOPHRENIA
IQ
DEPRESSION
DBH 5HTT SNAP-25
= dopamine transporter gene (DAT1)
= dopamine receptor gene (DRD)
D4
D5
= serotonin transporter gene5HTT
= others DBH HTR1Bm SNAP-25
2- Acquired Brain Injury
A prenatal Factors
CNS injury during Fetal Development
- Premature babies
-Traumainfectioncomplications
- Fetal exposure to drugs
- maternal smoking and maternal alcohol addiction
2- Acquired Brain Injury (cont)
B- CNS lesion during labour bull Type of Delivery can have impact if sudden or
extremely long and slow deliverybull Birth anoxia bull Weight at birth if SGA
C- Post Birth Factorsbull Cranial bleed bull Seizures bull Concussioncomabull Environmental chronic Lead poison
Environmental factors bull exposures to neurodevelopmental toxinstoxins
such as heavy metals and organohalide pollutants (lead mercury toxins -ldquoteratogensrdquo)
bull adverse responses to food additivesbull intolerances to foods (sugar )bull sensitivities to environmental chemicals
molds and fungi
Organochlorines and Child Development
bull Dichlorodiphenyl dichloroethylene(ppDDE) measured in umbilical cord blood
bull Serum levels were negatively associated with both mental and psychomotor development
bull The higher the serum level the worse the childs development at 13 months old
Recent studies suggest that causalpathways in some cases involve
complex interactions betweengenetic and environmental factors
2009
bull Less effective parenting - mother not in home father working more Everyone more stressed
bull Egypt educational curriculum and processbull Higher demands on childrenbull Toxins in the prenatal and early childhood environment (over
200 contaminants found in umbilical cord blood )
Why the Explosion in ADHD
MANAGEMENT
Recognition and Referral
OSHA PLAN OF MANAGEMENT
OF ADHD CHILD
Modified from AAP 2011
Recognition and Referral
Diagnosis (Assessment)
1+2+3
bull At present there is no biomedical laboratory test for ADHD
Neuropharmacology 57 (2009) 579ndash589
DD 70
DD for ADHD
bull 1- anxiety disordersbull 2- conduct disorderbull 3- oppositional defiant disorderbull 4- impulse-control or mood disordersbull 5- learning disordersbull 6- mental retardation
bull 7- gifted childrenbull 8- pervasive developmental disorders
DD for ADHD (contin)
bull 9- depression bull 10-Bipolar disorders Schizophrenia bull 11- Drugs PB CZP
bull 12- Misfits between the child and school or even the child and teacher
bull 13- substance abuse stimulants cocaine phenyclidine
bull 14- hyperthyroidismbull 15- BHL
bull
bull
Bip
ola
r D
iso
rder
Rule outs for the Diagnosis of ADHD
Myth ADHD child Can do bull Video Gamesbull Watch TVbull Computersbull Play Sportsbull Build Leggos
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
1- Hereditary ADHD
Twin adoption
ADHD Is highly heritable
HEIGHT
ADHD
SCHIZOPHRENIA
IQ
DEPRESSION
DBH 5HTT SNAP-25
= dopamine transporter gene (DAT1)
= dopamine receptor gene (DRD)
D4
D5
= serotonin transporter gene5HTT
= others DBH HTR1Bm SNAP-25
2- Acquired Brain Injury
A prenatal Factors
CNS injury during Fetal Development
- Premature babies
-Traumainfectioncomplications
- Fetal exposure to drugs
- maternal smoking and maternal alcohol addiction
2- Acquired Brain Injury (cont)
B- CNS lesion during labour bull Type of Delivery can have impact if sudden or
extremely long and slow deliverybull Birth anoxia bull Weight at birth if SGA
C- Post Birth Factorsbull Cranial bleed bull Seizures bull Concussioncomabull Environmental chronic Lead poison
Environmental factors bull exposures to neurodevelopmental toxinstoxins
such as heavy metals and organohalide pollutants (lead mercury toxins -ldquoteratogensrdquo)
bull adverse responses to food additivesbull intolerances to foods (sugar )bull sensitivities to environmental chemicals
molds and fungi
Organochlorines and Child Development
bull Dichlorodiphenyl dichloroethylene(ppDDE) measured in umbilical cord blood
bull Serum levels were negatively associated with both mental and psychomotor development
bull The higher the serum level the worse the childs development at 13 months old
Recent studies suggest that causalpathways in some cases involve
complex interactions betweengenetic and environmental factors
2009
bull Less effective parenting - mother not in home father working more Everyone more stressed
bull Egypt educational curriculum and processbull Higher demands on childrenbull Toxins in the prenatal and early childhood environment (over
200 contaminants found in umbilical cord blood )
Why the Explosion in ADHD
MANAGEMENT
Recognition and Referral
OSHA PLAN OF MANAGEMENT
OF ADHD CHILD
Modified from AAP 2011
Recognition and Referral
Diagnosis (Assessment)
1+2+3
bull At present there is no biomedical laboratory test for ADHD
Neuropharmacology 57 (2009) 579ndash589
DD 70
DD for ADHD
bull 1- anxiety disordersbull 2- conduct disorderbull 3- oppositional defiant disorderbull 4- impulse-control or mood disordersbull 5- learning disordersbull 6- mental retardation
bull 7- gifted childrenbull 8- pervasive developmental disorders
DD for ADHD (contin)
bull 9- depression bull 10-Bipolar disorders Schizophrenia bull 11- Drugs PB CZP
bull 12- Misfits between the child and school or even the child and teacher
bull 13- substance abuse stimulants cocaine phenyclidine
bull 14- hyperthyroidismbull 15- BHL
bull
bull
Bip
ola
r D
iso
rder
Rule outs for the Diagnosis of ADHD
Myth ADHD child Can do bull Video Gamesbull Watch TVbull Computersbull Play Sportsbull Build Leggos
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
ADHD Is highly heritable
HEIGHT
ADHD
SCHIZOPHRENIA
IQ
DEPRESSION
DBH 5HTT SNAP-25
= dopamine transporter gene (DAT1)
= dopamine receptor gene (DRD)
D4
D5
= serotonin transporter gene5HTT
= others DBH HTR1Bm SNAP-25
2- Acquired Brain Injury
A prenatal Factors
CNS injury during Fetal Development
- Premature babies
-Traumainfectioncomplications
- Fetal exposure to drugs
- maternal smoking and maternal alcohol addiction
2- Acquired Brain Injury (cont)
B- CNS lesion during labour bull Type of Delivery can have impact if sudden or
extremely long and slow deliverybull Birth anoxia bull Weight at birth if SGA
C- Post Birth Factorsbull Cranial bleed bull Seizures bull Concussioncomabull Environmental chronic Lead poison
Environmental factors bull exposures to neurodevelopmental toxinstoxins
such as heavy metals and organohalide pollutants (lead mercury toxins -ldquoteratogensrdquo)
bull adverse responses to food additivesbull intolerances to foods (sugar )bull sensitivities to environmental chemicals
molds and fungi
Organochlorines and Child Development
bull Dichlorodiphenyl dichloroethylene(ppDDE) measured in umbilical cord blood
bull Serum levels were negatively associated with both mental and psychomotor development
bull The higher the serum level the worse the childs development at 13 months old
Recent studies suggest that causalpathways in some cases involve
complex interactions betweengenetic and environmental factors
2009
bull Less effective parenting - mother not in home father working more Everyone more stressed
bull Egypt educational curriculum and processbull Higher demands on childrenbull Toxins in the prenatal and early childhood environment (over
200 contaminants found in umbilical cord blood )
Why the Explosion in ADHD
MANAGEMENT
Recognition and Referral
OSHA PLAN OF MANAGEMENT
OF ADHD CHILD
Modified from AAP 2011
Recognition and Referral
Diagnosis (Assessment)
1+2+3
bull At present there is no biomedical laboratory test for ADHD
Neuropharmacology 57 (2009) 579ndash589
DD 70
DD for ADHD
bull 1- anxiety disordersbull 2- conduct disorderbull 3- oppositional defiant disorderbull 4- impulse-control or mood disordersbull 5- learning disordersbull 6- mental retardation
bull 7- gifted childrenbull 8- pervasive developmental disorders
DD for ADHD (contin)
bull 9- depression bull 10-Bipolar disorders Schizophrenia bull 11- Drugs PB CZP
bull 12- Misfits between the child and school or even the child and teacher
bull 13- substance abuse stimulants cocaine phenyclidine
bull 14- hyperthyroidismbull 15- BHL
bull
bull
Bip
ola
r D
iso
rder
Rule outs for the Diagnosis of ADHD
Myth ADHD child Can do bull Video Gamesbull Watch TVbull Computersbull Play Sportsbull Build Leggos
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
= dopamine transporter gene (DAT1)
= dopamine receptor gene (DRD)
D4
D5
= serotonin transporter gene5HTT
= others DBH HTR1Bm SNAP-25
2- Acquired Brain Injury
A prenatal Factors
CNS injury during Fetal Development
- Premature babies
-Traumainfectioncomplications
- Fetal exposure to drugs
- maternal smoking and maternal alcohol addiction
2- Acquired Brain Injury (cont)
B- CNS lesion during labour bull Type of Delivery can have impact if sudden or
extremely long and slow deliverybull Birth anoxia bull Weight at birth if SGA
C- Post Birth Factorsbull Cranial bleed bull Seizures bull Concussioncomabull Environmental chronic Lead poison
Environmental factors bull exposures to neurodevelopmental toxinstoxins
such as heavy metals and organohalide pollutants (lead mercury toxins -ldquoteratogensrdquo)
bull adverse responses to food additivesbull intolerances to foods (sugar )bull sensitivities to environmental chemicals
molds and fungi
Organochlorines and Child Development
bull Dichlorodiphenyl dichloroethylene(ppDDE) measured in umbilical cord blood
bull Serum levels were negatively associated with both mental and psychomotor development
bull The higher the serum level the worse the childs development at 13 months old
Recent studies suggest that causalpathways in some cases involve
complex interactions betweengenetic and environmental factors
2009
bull Less effective parenting - mother not in home father working more Everyone more stressed
bull Egypt educational curriculum and processbull Higher demands on childrenbull Toxins in the prenatal and early childhood environment (over
200 contaminants found in umbilical cord blood )
Why the Explosion in ADHD
MANAGEMENT
Recognition and Referral
OSHA PLAN OF MANAGEMENT
OF ADHD CHILD
Modified from AAP 2011
Recognition and Referral
Diagnosis (Assessment)
1+2+3
bull At present there is no biomedical laboratory test for ADHD
Neuropharmacology 57 (2009) 579ndash589
DD 70
DD for ADHD
bull 1- anxiety disordersbull 2- conduct disorderbull 3- oppositional defiant disorderbull 4- impulse-control or mood disordersbull 5- learning disordersbull 6- mental retardation
bull 7- gifted childrenbull 8- pervasive developmental disorders
DD for ADHD (contin)
bull 9- depression bull 10-Bipolar disorders Schizophrenia bull 11- Drugs PB CZP
bull 12- Misfits between the child and school or even the child and teacher
bull 13- substance abuse stimulants cocaine phenyclidine
bull 14- hyperthyroidismbull 15- BHL
bull
bull
Bip
ola
r D
iso
rder
Rule outs for the Diagnosis of ADHD
Myth ADHD child Can do bull Video Gamesbull Watch TVbull Computersbull Play Sportsbull Build Leggos
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
2- Acquired Brain Injury
A prenatal Factors
CNS injury during Fetal Development
- Premature babies
-Traumainfectioncomplications
- Fetal exposure to drugs
- maternal smoking and maternal alcohol addiction
2- Acquired Brain Injury (cont)
B- CNS lesion during labour bull Type of Delivery can have impact if sudden or
extremely long and slow deliverybull Birth anoxia bull Weight at birth if SGA
C- Post Birth Factorsbull Cranial bleed bull Seizures bull Concussioncomabull Environmental chronic Lead poison
Environmental factors bull exposures to neurodevelopmental toxinstoxins
such as heavy metals and organohalide pollutants (lead mercury toxins -ldquoteratogensrdquo)
bull adverse responses to food additivesbull intolerances to foods (sugar )bull sensitivities to environmental chemicals
molds and fungi
Organochlorines and Child Development
bull Dichlorodiphenyl dichloroethylene(ppDDE) measured in umbilical cord blood
bull Serum levels were negatively associated with both mental and psychomotor development
bull The higher the serum level the worse the childs development at 13 months old
Recent studies suggest that causalpathways in some cases involve
complex interactions betweengenetic and environmental factors
2009
bull Less effective parenting - mother not in home father working more Everyone more stressed
bull Egypt educational curriculum and processbull Higher demands on childrenbull Toxins in the prenatal and early childhood environment (over
200 contaminants found in umbilical cord blood )
Why the Explosion in ADHD
MANAGEMENT
Recognition and Referral
OSHA PLAN OF MANAGEMENT
OF ADHD CHILD
Modified from AAP 2011
Recognition and Referral
Diagnosis (Assessment)
1+2+3
bull At present there is no biomedical laboratory test for ADHD
Neuropharmacology 57 (2009) 579ndash589
DD 70
DD for ADHD
bull 1- anxiety disordersbull 2- conduct disorderbull 3- oppositional defiant disorderbull 4- impulse-control or mood disordersbull 5- learning disordersbull 6- mental retardation
bull 7- gifted childrenbull 8- pervasive developmental disorders
DD for ADHD (contin)
bull 9- depression bull 10-Bipolar disorders Schizophrenia bull 11- Drugs PB CZP
bull 12- Misfits between the child and school or even the child and teacher
bull 13- substance abuse stimulants cocaine phenyclidine
bull 14- hyperthyroidismbull 15- BHL
bull
bull
Bip
ola
r D
iso
rder
Rule outs for the Diagnosis of ADHD
Myth ADHD child Can do bull Video Gamesbull Watch TVbull Computersbull Play Sportsbull Build Leggos
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
2- Acquired Brain Injury (cont)
B- CNS lesion during labour bull Type of Delivery can have impact if sudden or
extremely long and slow deliverybull Birth anoxia bull Weight at birth if SGA
C- Post Birth Factorsbull Cranial bleed bull Seizures bull Concussioncomabull Environmental chronic Lead poison
Environmental factors bull exposures to neurodevelopmental toxinstoxins
such as heavy metals and organohalide pollutants (lead mercury toxins -ldquoteratogensrdquo)
bull adverse responses to food additivesbull intolerances to foods (sugar )bull sensitivities to environmental chemicals
molds and fungi
Organochlorines and Child Development
bull Dichlorodiphenyl dichloroethylene(ppDDE) measured in umbilical cord blood
bull Serum levels were negatively associated with both mental and psychomotor development
bull The higher the serum level the worse the childs development at 13 months old
Recent studies suggest that causalpathways in some cases involve
complex interactions betweengenetic and environmental factors
2009
bull Less effective parenting - mother not in home father working more Everyone more stressed
bull Egypt educational curriculum and processbull Higher demands on childrenbull Toxins in the prenatal and early childhood environment (over
200 contaminants found in umbilical cord blood )
Why the Explosion in ADHD
MANAGEMENT
Recognition and Referral
OSHA PLAN OF MANAGEMENT
OF ADHD CHILD
Modified from AAP 2011
Recognition and Referral
Diagnosis (Assessment)
1+2+3
bull At present there is no biomedical laboratory test for ADHD
Neuropharmacology 57 (2009) 579ndash589
DD 70
DD for ADHD
bull 1- anxiety disordersbull 2- conduct disorderbull 3- oppositional defiant disorderbull 4- impulse-control or mood disordersbull 5- learning disordersbull 6- mental retardation
bull 7- gifted childrenbull 8- pervasive developmental disorders
DD for ADHD (contin)
bull 9- depression bull 10-Bipolar disorders Schizophrenia bull 11- Drugs PB CZP
bull 12- Misfits between the child and school or even the child and teacher
bull 13- substance abuse stimulants cocaine phenyclidine
bull 14- hyperthyroidismbull 15- BHL
bull
bull
Bip
ola
r D
iso
rder
Rule outs for the Diagnosis of ADHD
Myth ADHD child Can do bull Video Gamesbull Watch TVbull Computersbull Play Sportsbull Build Leggos
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
Environmental factors bull exposures to neurodevelopmental toxinstoxins
such as heavy metals and organohalide pollutants (lead mercury toxins -ldquoteratogensrdquo)
bull adverse responses to food additivesbull intolerances to foods (sugar )bull sensitivities to environmental chemicals
molds and fungi
Organochlorines and Child Development
bull Dichlorodiphenyl dichloroethylene(ppDDE) measured in umbilical cord blood
bull Serum levels were negatively associated with both mental and psychomotor development
bull The higher the serum level the worse the childs development at 13 months old
Recent studies suggest that causalpathways in some cases involve
complex interactions betweengenetic and environmental factors
2009
bull Less effective parenting - mother not in home father working more Everyone more stressed
bull Egypt educational curriculum and processbull Higher demands on childrenbull Toxins in the prenatal and early childhood environment (over
200 contaminants found in umbilical cord blood )
Why the Explosion in ADHD
MANAGEMENT
Recognition and Referral
OSHA PLAN OF MANAGEMENT
OF ADHD CHILD
Modified from AAP 2011
Recognition and Referral
Diagnosis (Assessment)
1+2+3
bull At present there is no biomedical laboratory test for ADHD
Neuropharmacology 57 (2009) 579ndash589
DD 70
DD for ADHD
bull 1- anxiety disordersbull 2- conduct disorderbull 3- oppositional defiant disorderbull 4- impulse-control or mood disordersbull 5- learning disordersbull 6- mental retardation
bull 7- gifted childrenbull 8- pervasive developmental disorders
DD for ADHD (contin)
bull 9- depression bull 10-Bipolar disorders Schizophrenia bull 11- Drugs PB CZP
bull 12- Misfits between the child and school or even the child and teacher
bull 13- substance abuse stimulants cocaine phenyclidine
bull 14- hyperthyroidismbull 15- BHL
bull
bull
Bip
ola
r D
iso
rder
Rule outs for the Diagnosis of ADHD
Myth ADHD child Can do bull Video Gamesbull Watch TVbull Computersbull Play Sportsbull Build Leggos
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
Organochlorines and Child Development
bull Dichlorodiphenyl dichloroethylene(ppDDE) measured in umbilical cord blood
bull Serum levels were negatively associated with both mental and psychomotor development
bull The higher the serum level the worse the childs development at 13 months old
Recent studies suggest that causalpathways in some cases involve
complex interactions betweengenetic and environmental factors
2009
bull Less effective parenting - mother not in home father working more Everyone more stressed
bull Egypt educational curriculum and processbull Higher demands on childrenbull Toxins in the prenatal and early childhood environment (over
200 contaminants found in umbilical cord blood )
Why the Explosion in ADHD
MANAGEMENT
Recognition and Referral
OSHA PLAN OF MANAGEMENT
OF ADHD CHILD
Modified from AAP 2011
Recognition and Referral
Diagnosis (Assessment)
1+2+3
bull At present there is no biomedical laboratory test for ADHD
Neuropharmacology 57 (2009) 579ndash589
DD 70
DD for ADHD
bull 1- anxiety disordersbull 2- conduct disorderbull 3- oppositional defiant disorderbull 4- impulse-control or mood disordersbull 5- learning disordersbull 6- mental retardation
bull 7- gifted childrenbull 8- pervasive developmental disorders
DD for ADHD (contin)
bull 9- depression bull 10-Bipolar disorders Schizophrenia bull 11- Drugs PB CZP
bull 12- Misfits between the child and school or even the child and teacher
bull 13- substance abuse stimulants cocaine phenyclidine
bull 14- hyperthyroidismbull 15- BHL
bull
bull
Bip
ola
r D
iso
rder
Rule outs for the Diagnosis of ADHD
Myth ADHD child Can do bull Video Gamesbull Watch TVbull Computersbull Play Sportsbull Build Leggos
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
Recent studies suggest that causalpathways in some cases involve
complex interactions betweengenetic and environmental factors
2009
bull Less effective parenting - mother not in home father working more Everyone more stressed
bull Egypt educational curriculum and processbull Higher demands on childrenbull Toxins in the prenatal and early childhood environment (over
200 contaminants found in umbilical cord blood )
Why the Explosion in ADHD
MANAGEMENT
Recognition and Referral
OSHA PLAN OF MANAGEMENT
OF ADHD CHILD
Modified from AAP 2011
Recognition and Referral
Diagnosis (Assessment)
1+2+3
bull At present there is no biomedical laboratory test for ADHD
Neuropharmacology 57 (2009) 579ndash589
DD 70
DD for ADHD
bull 1- anxiety disordersbull 2- conduct disorderbull 3- oppositional defiant disorderbull 4- impulse-control or mood disordersbull 5- learning disordersbull 6- mental retardation
bull 7- gifted childrenbull 8- pervasive developmental disorders
DD for ADHD (contin)
bull 9- depression bull 10-Bipolar disorders Schizophrenia bull 11- Drugs PB CZP
bull 12- Misfits between the child and school or even the child and teacher
bull 13- substance abuse stimulants cocaine phenyclidine
bull 14- hyperthyroidismbull 15- BHL
bull
bull
Bip
ola
r D
iso
rder
Rule outs for the Diagnosis of ADHD
Myth ADHD child Can do bull Video Gamesbull Watch TVbull Computersbull Play Sportsbull Build Leggos
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
bull Less effective parenting - mother not in home father working more Everyone more stressed
bull Egypt educational curriculum and processbull Higher demands on childrenbull Toxins in the prenatal and early childhood environment (over
200 contaminants found in umbilical cord blood )
Why the Explosion in ADHD
MANAGEMENT
Recognition and Referral
OSHA PLAN OF MANAGEMENT
OF ADHD CHILD
Modified from AAP 2011
Recognition and Referral
Diagnosis (Assessment)
1+2+3
bull At present there is no biomedical laboratory test for ADHD
Neuropharmacology 57 (2009) 579ndash589
DD 70
DD for ADHD
bull 1- anxiety disordersbull 2- conduct disorderbull 3- oppositional defiant disorderbull 4- impulse-control or mood disordersbull 5- learning disordersbull 6- mental retardation
bull 7- gifted childrenbull 8- pervasive developmental disorders
DD for ADHD (contin)
bull 9- depression bull 10-Bipolar disorders Schizophrenia bull 11- Drugs PB CZP
bull 12- Misfits between the child and school or even the child and teacher
bull 13- substance abuse stimulants cocaine phenyclidine
bull 14- hyperthyroidismbull 15- BHL
bull
bull
Bip
ola
r D
iso
rder
Rule outs for the Diagnosis of ADHD
Myth ADHD child Can do bull Video Gamesbull Watch TVbull Computersbull Play Sportsbull Build Leggos
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
MANAGEMENT
Recognition and Referral
OSHA PLAN OF MANAGEMENT
OF ADHD CHILD
Modified from AAP 2011
Recognition and Referral
Diagnosis (Assessment)
1+2+3
bull At present there is no biomedical laboratory test for ADHD
Neuropharmacology 57 (2009) 579ndash589
DD 70
DD for ADHD
bull 1- anxiety disordersbull 2- conduct disorderbull 3- oppositional defiant disorderbull 4- impulse-control or mood disordersbull 5- learning disordersbull 6- mental retardation
bull 7- gifted childrenbull 8- pervasive developmental disorders
DD for ADHD (contin)
bull 9- depression bull 10-Bipolar disorders Schizophrenia bull 11- Drugs PB CZP
bull 12- Misfits between the child and school or even the child and teacher
bull 13- substance abuse stimulants cocaine phenyclidine
bull 14- hyperthyroidismbull 15- BHL
bull
bull
Bip
ola
r D
iso
rder
Rule outs for the Diagnosis of ADHD
Myth ADHD child Can do bull Video Gamesbull Watch TVbull Computersbull Play Sportsbull Build Leggos
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
Recognition and Referral
OSHA PLAN OF MANAGEMENT
OF ADHD CHILD
Modified from AAP 2011
Recognition and Referral
Diagnosis (Assessment)
1+2+3
bull At present there is no biomedical laboratory test for ADHD
Neuropharmacology 57 (2009) 579ndash589
DD 70
DD for ADHD
bull 1- anxiety disordersbull 2- conduct disorderbull 3- oppositional defiant disorderbull 4- impulse-control or mood disordersbull 5- learning disordersbull 6- mental retardation
bull 7- gifted childrenbull 8- pervasive developmental disorders
DD for ADHD (contin)
bull 9- depression bull 10-Bipolar disorders Schizophrenia bull 11- Drugs PB CZP
bull 12- Misfits between the child and school or even the child and teacher
bull 13- substance abuse stimulants cocaine phenyclidine
bull 14- hyperthyroidismbull 15- BHL
bull
bull
Bip
ola
r D
iso
rder
Rule outs for the Diagnosis of ADHD
Myth ADHD child Can do bull Video Gamesbull Watch TVbull Computersbull Play Sportsbull Build Leggos
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
Recognition and Referral
Diagnosis (Assessment)
1+2+3
bull At present there is no biomedical laboratory test for ADHD
Neuropharmacology 57 (2009) 579ndash589
DD 70
DD for ADHD
bull 1- anxiety disordersbull 2- conduct disorderbull 3- oppositional defiant disorderbull 4- impulse-control or mood disordersbull 5- learning disordersbull 6- mental retardation
bull 7- gifted childrenbull 8- pervasive developmental disorders
DD for ADHD (contin)
bull 9- depression bull 10-Bipolar disorders Schizophrenia bull 11- Drugs PB CZP
bull 12- Misfits between the child and school or even the child and teacher
bull 13- substance abuse stimulants cocaine phenyclidine
bull 14- hyperthyroidismbull 15- BHL
bull
bull
Bip
ola
r D
iso
rder
Rule outs for the Diagnosis of ADHD
Myth ADHD child Can do bull Video Gamesbull Watch TVbull Computersbull Play Sportsbull Build Leggos
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
bull At present there is no biomedical laboratory test for ADHD
Neuropharmacology 57 (2009) 579ndash589
DD 70
DD for ADHD
bull 1- anxiety disordersbull 2- conduct disorderbull 3- oppositional defiant disorderbull 4- impulse-control or mood disordersbull 5- learning disordersbull 6- mental retardation
bull 7- gifted childrenbull 8- pervasive developmental disorders
DD for ADHD (contin)
bull 9- depression bull 10-Bipolar disorders Schizophrenia bull 11- Drugs PB CZP
bull 12- Misfits between the child and school or even the child and teacher
bull 13- substance abuse stimulants cocaine phenyclidine
bull 14- hyperthyroidismbull 15- BHL
bull
bull
Bip
ola
r D
iso
rder
Rule outs for the Diagnosis of ADHD
Myth ADHD child Can do bull Video Gamesbull Watch TVbull Computersbull Play Sportsbull Build Leggos
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
DD for ADHD
bull 1- anxiety disordersbull 2- conduct disorderbull 3- oppositional defiant disorderbull 4- impulse-control or mood disordersbull 5- learning disordersbull 6- mental retardation
bull 7- gifted childrenbull 8- pervasive developmental disorders
DD for ADHD (contin)
bull 9- depression bull 10-Bipolar disorders Schizophrenia bull 11- Drugs PB CZP
bull 12- Misfits between the child and school or even the child and teacher
bull 13- substance abuse stimulants cocaine phenyclidine
bull 14- hyperthyroidismbull 15- BHL
bull
bull
Bip
ola
r D
iso
rder
Rule outs for the Diagnosis of ADHD
Myth ADHD child Can do bull Video Gamesbull Watch TVbull Computersbull Play Sportsbull Build Leggos
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
DD for ADHD (contin)
bull 9- depression bull 10-Bipolar disorders Schizophrenia bull 11- Drugs PB CZP
bull 12- Misfits between the child and school or even the child and teacher
bull 13- substance abuse stimulants cocaine phenyclidine
bull 14- hyperthyroidismbull 15- BHL
bull
bull
Bip
ola
r D
iso
rder
Rule outs for the Diagnosis of ADHD
Myth ADHD child Can do bull Video Gamesbull Watch TVbull Computersbull Play Sportsbull Build Leggos
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
Bip
ola
r D
iso
rder
Rule outs for the Diagnosis of ADHD
Myth ADHD child Can do bull Video Gamesbull Watch TVbull Computersbull Play Sportsbull Build Leggos
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
Rule outs for the Diagnosis of ADHD
Myth ADHD child Can do bull Video Gamesbull Watch TVbull Computersbull Play Sportsbull Build Leggos
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
Rule outs for the Diagnosis of ADHD
Myth 2-respond to medicationsbull 20-30 of ADHD children do NOT
respondbull Only 50 -55 respond academically when
medicated bull 20-25 respond to medications (False
Positives) in no ADHD children
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
Criteria for ADHD Diagnosis (cont)
1- the symptoms of ADHD must have been present for at least 6 months before the diagnosis can be established
2-have an onset before age 7
DSM-IV criteria
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
Criteria for ADHD (cont) Diagnosis
3- Causes significant problems at least in two different settings (home and school ) of ASE
DSN-IV criteria
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
Medical
FAMILYCHILD
Environment
OSHA TRIANGLE ASSESSMENT
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
OSHA TRIANGLE ASSESSMENT
Medical
FAMILYCHILD
Environment
DD 701- DSM 42- connerrsquos
psychological Profile Intellecual and cognitive FDevelopmentalacademic Skills learning readiness and achievement Individual scholastic and social adjustment(behav rating scale)Motor adjustment and coordinationlanguage and speech assessment and evaluation including academic language
Parental Attitude and Family adjustment
Teacher Q
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
DSMsubtypes
INATTENTIVECOMBINED HYPERKINETIC
60 103060
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
Parental Altitude
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
OCD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
Dyslexia
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
Dyslexia
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
anxiety
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
The Diagnosis of ADHDNO ROLE OF
bull Laboratory tests
bull Brain CTMRI
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
EEG
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
Imaging Studies (MRI)1 Reduction of total brain size
2 Reduction of certain brain regions ndash prefrontal cortex (thin)
3 Structural changes in the caudate and putamen
4 Decrease blood flow in the striatum
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
Assessment Team
bull Must get the story from all sides -the child the family the school and significant others
bull Careful thorough exploration of all the issues before leaping to conclusions
The Diagnosis of ADHD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
Recognition and Referral
Assessment
Initiation of treatment
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
Agenda
Impact of ADHD on everyday life
Should we treat ADHD
How do we treat ADHD
Opinion
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
Untreated ADHD Parentsrsquo consequencesbull Chronic stressed or worried about childrsquos ADHD
bull Frustration
bull Blaming guilt
bull Social isolation
bull Parentsrsquo marriage has been negatively affected
bull Economic burden
Rule 2
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
No ldquomagic curerdquo
bull There is no ldquoquick fixrdquo
bull No single intervention will correct the problems for every child-need a toolbox
Rule 3
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
Treatment needs to target not only the core symptoms but
also co-morbid and coexisting disorders and
other psychosocial adversities
Rule 4
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
Parentsrsquo Fear of Medications for ADHD
bull Dependence bull Change personality or IQbull Being labeled attribution problemsbull Reactions of others ndash teachers peers
familybull Use special prescriptionbull Cost bull Lastly anorexia insomnia tics height
suicide
Role 5MEDICATION
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
OSHA Protocol of B- treatment
Familyrole
Child role
Medicine
Environment
1- Family counseling2- Group therapy
Drug
1-Behavior modification sessions2-Academic sessions3- Group therapy ( ADHD DAY)
Teacher orientationClass guidance
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
Family Group Therapy
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
Full Day Activity
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
MEDICINECRITERIA FOR CHOICE
bull 1- not before age 6 yearsbull 2- compliancebull 3- availablebull 4- no other effects
bull 5- specific and not symptomatic
bull 6- Results of a Pan-European Survey ADHD impact across the day
MEDICATION
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
Medications
Stimulants Non-stimulants
Others
Methylphenidate
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
Drugs Used For Treatment Approved by FDA
Stimulants
a) Methylphenidate
b) Dextro-amphetamines ( not available)
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
Forms of Methylphenidate
bull
a) short acting 3-6 hrs
Ritalin (10mg)
c) once daily
Concerta (ER)
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
Methylphenidate (Ritalin)
action Increases release of norepinephrine and dopamine in the cerebral cortex to reticular activating system
bull Onset 05-1hr bull Maximum 3 hrbull duration 4-6 hr bull metabolized by liverbull excreted by kidneys
03 -08 mgkgdoselowest dose 7daysweek
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
Ritalin (methylphenidate)bull paradoxical affect to increase attention
span and calming effect bull Dose -breakfast and lunch increase by
01gkg dose or by 5-10mgdose at weekly intervals Max dose 2mgkgday or 60mgday
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
Concerta (ER) (18 27 36 and 54 mg) ( 11- 12 H)
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
Other Forms of Methylphenidate
bull a) short acting 3-6 hrs Focalin ( isomere of methylphenidate) (25 5 10 mg) (Out
recently)
b) intermediate acting 6-8 hrs SR Ritalin (Ciba 20 mg) (not recommended Metadate ER c) once daily ( 8+ hrs) Metadate CD
Ritalin LA (20 30 40 mg) (Sprinkle) e) recent route transdermal MPH (daytrana)
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
rebound agitation or exaggeration of pre-medication symptoms as it is wearing off
Other effects gt SE
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
contraindicationsbull Ticsbull Failure to thrivebull Epilepsybull MAO inhibitors ( absolute contraindication)bull Allergy to ritalin (absolute contraindication)bull glaucoma
PrecautionsUse cautiously in patients with marked anxiety motor tics or with family history of Tourette syndrome or history of substance abuse
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
Medications
Stimulants Non-stimulants
Others
Ritalinconcerta atomoxetine
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
Drugs Used For Treatment FDA approval (non stimulant)
Atomoxetine= Selective Nor-epinephrine reuptake inhibitors
Since 2002
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
Atomoxetine for ADHD
bull ADHD with epilepsy bull ADHD with depressionbull ADHD in ASD bull ADHD with tics
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
Atomoxetine for ADHD
bull Safebull Single dosebull Effectivebull Doses follow mgkg dosing bull benefits tend to persist into evening amp
sometimes into morning
No insomniaNight concentration
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
Rational for a non-stimulant medication for treatment of ADHD
1- poor response or tolerability in some patients
2- act for a maximum of 12 hrs
3- suboptimal response is not uncommon
4- relative or contraindicated for some co-morbid conditions as tics anxiety substance abuse
5- some parents refuse stimulants
6- risk for abuse
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
Atomoxetine is specific for mechanism treatment
Persist after no medicine
Can be stopped with still benefit
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
Atomoxetine for ADHD
bull Start 05- 08 mgkgdbull Target 12 mgkgdbull Available in 10mg 18mg 25mg 40mg and
60mg strengths bull Some improvements may be seen in 1 ndash 2
wks full effects not until 6-8 wks
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
Atomoxetinebull Rapidly absorbed after oral intakebull Absorption unaffected by foodbull Brain concentrations gt plasma
concentrations bull Metabolized by P450 2D6 (neither inhibits
nor induces)bull ~ 80 of dose excreted in urine
Data on file Ell Lilly and Company
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
Side effects of Atomoxetine
bull Anorexiabull Dyspepsia bull Nauseabull Emesis bull Sedation bull Fatigue bull insomniabull Dizziness bull Mood swingsbull Growth delay
July 2007 Dev Med Ch Neurol
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
Medications
Stimulants Non-stimulants
Others
1- buproprion
2- resperidone
3- catapres
4- Benefit
- LCPUFA
Ritalinconcerta
atomoxetine
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
Drugs Used For Treatment (others)
Antidepressant
Buproprion (Wellbutrin)
=Antidepressant (norephinephrinedopamine reuptake inhibitor)
150 mg tab
ADHD + ANXIETY OR DEPRESSION
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
Other Antidepressant
Tricyclics
imipramine desipramine nortriptyline
Always monitor cardiovascular side effects
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
Risperidone
bull Action Unclear but may be related to antagonism for dopamine and serotonin receptors bull Peak plasma level in 1-2 hr bull Hepatic metabolismbull excreted by liverbull Side effects dry mouth stomatitis taste alteration (rare)
)
ADHD + ASD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
Alpha2 antagonist
bull antihypertensives Clonidine (catapres)bull Guanfacine
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
ldquoCod Liver Oil ldquoLCPUFA
bull cod liver oil contains vitamins A and D and has a different concentration of omega3 (EFA)
bull Promotes normal bone formation vision and reproduction
bull Promotes immunitybull Promotes appetitebull Promotes concentration amd mental functionbull For autism ADHDADD
