ADHD and Psychopharmacology By Monica Robles M.D.
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Transcript of ADHD and Psychopharmacology By Monica Robles M.D.
![Page 1: ADHD and Psychopharmacology By Monica Robles M.D.](https://reader036.fdocuments.net/reader036/viewer/2022062516/56649e235503460f94b1002f/html5/thumbnails/1.jpg)
ADHD and Psychopharmacology
By Monica Robles M.D
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ADHD: prevalence and treatment
• Recent studies suggests that ADHD is under diagnosed in the US
• 1300 children were interviewed in 4 US communities
• 5% met criteria for ADHD
• Only 14% of them had been treated with medication in the past 12 months
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Pharmacotherapy ADHD
• It is the cornerstone of treatment
• Decision to treat should be based on severity of symptoms
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Impairment related to ADHD
• Psychiatric comorbidity• School failure• Peer relationship dysfunction• Legal difficulties• Smoking and substance abuse• Accidents and injuries• Family conflict• Parent stress
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MTA study
• 579 kids ages 7-9 with ADHD were studied for 14 months
1.Medication management by child psychiatrist
2.Behavioral therapy
3.Combination of medication and therapy
4.Community visits with the pediatrician
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Results MTA study
• All the treatment groups were effective
• BUT MEDICATION MANAGEMENT ALONE BETTER THAN COMBINATION
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Summary of the study
• Well delivered medication may be enough for the treatment of ADHD
• Behavioral management is also an acceptable method for those who prefer not to use medication
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ATTENTION: ask for therapy
• Parent-child conflict or family stress
• Serious academic difficulties
• Social skills
• Anxiety symptoms or depression
• Oppositional or aggressive symptoms
• If the family wants it.
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ADHD pharmacotherapy
• ADHD has largest body of data of any medication treatment for childhood psychiatric disorder
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What do stimulants do
Improve core symptoms of ADHD inattention Impulsivity hyperactivity
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What do stimulants do
noncomplianceImpulsive aggressionSocial interactionAcademic efficiencyAcademic accuracyEnhanced vigilanceImprove reaction timeImprove short term memory
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Stimulants: mechanism of action
• They work inside of our brain controlling release of neurotransmitters and inhibiting reuptake
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Stimulants
Methylphenidate
Amphetamine preparations
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Stimulants
• Short-acting
Focalin, Methylin, Ritalin
• Intermediate-acting
Metadate ER and CD, Methylin ER,Ritalin LA and SR
• Long-acting
Concerta, Focalin XR and Daytrana
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Stimulants: amphetamine
• Short-acting
Adderall , Dexedrine, Dextrostat
• Long-acting
Adderall XR, Dexedrine Spansule, Vyvanse
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Stimulants(adverse effects)
• Use caution in
hx of drug dependency and alcoholism
Serious cardiac history
history of psychotic symptoms or bipolar disorder
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Stimulants side effects
• Decrease appetite
• Gastrointestinal
problems
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Stimulants side effects
• Headache
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Stimulants side effects
• Sleep difficulties
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Stimulants side effects
• Jitteriness
• Irritability
• Anxiety
• Depression
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Stimulants side effects
• Psychosis and paranoia
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Stimulants side effects
• Tics or abnormal movements
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Stimulants side effects
• Nail biting
• Skin picking
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Stimulants side effects
• Rebound
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Stimulants side effects
• Cardiac side effects
1.Increases blood pressure
2.Cardiac complications
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Areas of concern and controversy
• When to do EKG
Family history of sudden death
Personal history of congenital cardiac defects
syncope,CP, palpitation or increase BP
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Stimulants side effects
• Growth Effects
Adult height appears to be uncompromised
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Abuse potential of stimulants
• No scientific data that ADHD children abuse meds when appropriately administered.
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Alternatives to stimulants
Around 15% nonresponders
Intolerable side effects
Symptom rebound
Complicated ADHD with comorbidity.
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Alternatives to stimulants
• Atomoxetine(Strattera)
• Tricyclic antidepressants
• Clonidine and guanfacine
• Bupropion
• Others
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Atomoxetine
• Approved by FDA 2002
• Non stimulant med approved for kids and adults
• Selective NE reuptake inhibitor
• Minimum abuse potential
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Atomoxetine side effects
• Appetite suppression
• Sleep disturbance
• Jitteriness and irritability
• NAUSEA
• Small increase of pulse and Blood pressure
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Black Box warning
• Hepatitis( 2 cases)
Notify doctor if: dark urine, abdominal pain , yellow skin or eyes.
• Suicidality
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Atomoxetine benefits
• It lasts all day
• Little or no rebound
• No abuse potential
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Non-pharmacological treatment
• Education and Support: parent centered advocacy groups such as CHADD
• Decrease stimulation and increase structure
• School intervention
• Parent therapy/guidance (behavioral)
• Social skills therapy
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School intervention
• Evaluate for comorbid learning disabilities
• Provide special education support
• Classroom accommodations
• Resource room if needed( smaller classroom)
• Aides in the class
• Individual tutoring
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Psychosocial therapy
• Child’s ADHD symptoms are mild with minimal impairment
• Uncertainty of ADHD diagnosis• Marked disagreement about ADHD
diagnosis• Preference of the family• Presence of comorbid disorders or
problems that usually respond to therapy• Family problems need to be address
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Summary :ADHD treatment• We need to recognize ADHD as a chronic disorder• Define the target behaviors• Create an alliance that will include
patient/parents/teacher and clinician• Provide patient and parents education about ADHD• Make a rational decision about the use of
medication• Include psychosocial therapy when needed• SYSTEMATIC MONITORING , REVIEW and
FOLLOW UP