ADHS Treatment Basics

Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta. ©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.

Treatment Basics for ADHD

Roy Q. Sanders, MD

Medical Director

Marcus Autism Center

2 Marcus Autism Center is an affiliate of Children’s Healthcare of Atlanta. ©2006 Children’s Healthcare of Atlanta Inc. All rights reserved.

Introduction

One of the most common childhood psychiatric diagnoses. ADHD effect 4-7 % of children and generally persists into Adulthood. There are significant issues with co-morbidity including but not limited to conduct disorder, intellectual and learning issues, as well as substance abuse.


After Diagnosis

The symptoms of poor attention, poor concentration, hyperactivity and impulsivity are probably the final common pathway of different basic neurological function.

Clues in history and examination lead to an exact understanding of what the problems are and how to proceed with treatment. Are there other diagnoses or complicating factors that may require referral?

Try to tease out etiology to create an appropriate comprehensive treatment plan.


Treatment Planning

• After trying to figure out the causes of the symptoms the treatment plan begins by determining the specific behaviors that are problematic and then setting up a specific behavior plan to address those behaviors.

• Schools and others caretaker should be involved in this phase of treatment planning.


Other Helpful Interventions

The information that I give to parents includes changes in the child’s environment and the family’s life style.• No television during the week and only limited television on

the weekend, parents watching with children• Restricted computer games and limited handheld and other

video games.• One hour of outside activity every day for home and included

in any IEP at school. • Daily aerobic exercise.• Parents must sit and eat one meal with the children• Breakfast every day and increased protein content. Limit dyes

and preservatives. Other diet changes if parents recognize problems.

• I tell parents they need to stop smoking.


Alternative Treatments

Other parents I have worked with are more comfortable and even more eager to try environmental/alternative treatments• We have used with varying success referrals

for massage therapy, acupressure / acupuncture, chiropractic consultation.

• Some parents opt for private or even home schooling


One of the most common reasons psychoactive medication is prescribed in children is related to problems associated with disruptive behavior. In particular problems with concentration, and arousal regulation. These difficulties are most often diagnosed as ADHD.

Medications


Medication Commonly Prescribed for Problems of Attention, Concentration and Arousal

Regulation

There are several classes of medication that are commonly prescribed to help with these symptoms. The class of medications most often prescribed is the stimulant class. Others types of medications include some antihypertensive medications, antidepressant medications, anticonvulsant medications and even anti-psychotics. We will explore these medication groups and some specific medications within these groups.


Stimulant Medications

Basically there are two classes of stimulant medications. There are methylphenidates and amphetamines.


Methylphenidate (Ritalin) is one of the oldest of the stimulant medications used in the treatment of attention and concentration problems. In general, methylphenidate is well tolerated and works well to increase concentration and attention and to decrease hyperactivity. It works about 80% of the time to reduce up to 80% of the symptoms a person is experiencing.

Methylphenidate


Methylphenidate

Side effects include decreased appetite, decreased or disturbed sleep, sometimes headaches and gastrointestinal pains. At times motor or vocal tics emerge. There can also be problems with mood instability and with irritability. In overdose you can see psychotic symptoms or symptoms of delirium.


Methylphenidate

Problems can also arise with methylphenidate because of the short half-life of the standard formulation. Theoretically dosing can occur every four hours but clinical experience leads to dosing as frequently as very 150 minutes. There are other forms of the medication that have longer duration of action including but not limited to Ritalin LA, Metadate CD, Concerta, and most recently the Daytrana patch.


D-Methlyphenidate

D-Methylphenidate is the “dextro” form of methylphenidate. The trade for this stimulant is Focalin. There are currently short acting form of Focalin and extended release form of the medication. Efficacy and side effects for this agent are similar to other stimulant medications.


Mixed Amphetamine Salts

Mixed amphetamine salts have also been available in the treatment of attention and concentration for many years. They are currently available in generic and under the trade name of Adderall and AdderallXR.

These medications are very effective in decreasing the symptoms of poor attention, poor concentration, and hyperactivity. Their effectiveness is similar to methylphenidate and they are very widely used.


Mixed Amphetamine Salts

Side effects are also similar to those listed above with methylphenidate but in clinical experience they are slightly more likely to create some mood lability and irritability than the other stimulant medications.


Lisdexamfetamine(Vyvanse)

A prodrug consisting of the psycho stimulant d-amphetamine coupled with the essential amino acid L-Lysine. Lisdexamfetamine was developed so that the psychostimulant is released and activated more slowly as the prodrug molecule is hydrolyzed—consequently cleaving off the amino acid-during the first pass through the intestines and/or the liver.


Dextroamphetamine

Dextroamphetamine has also been used for years in the treatment of problems with attention, concentration and the regulation of activity level.

Dextroamphetamine is effective in reduction of symptoms at a level consistent with the treatments listed above.

Side effects are similar to those listed above.


Atomoxitine (Strattera)

A noradrenergic reuptake inhibiter that appears to have relatively good effectiveness in decreasing levels of hyperactivity and in helping with increasing attention, concentration, and organization. It has been approved for use in children as young as 6 years old weighing above forty pounds. It generally has lasting effects throughout the day and into the evening. Problems have included changes in appetite and also nausea along with some sleep problems


Other Medication Options for Attention, Concentration and Over activity

The mainstay of therapy for problems with concentration and attention is stimulant medication. While stimulants are very effective medications there have been problems with their use because of the relatively short half life of each of these preparations. Even at their longest the medications rarely last greater than 8 hours and often times patients can experience a sort of rebound hyperactivity once the medication has “worn off”.


Centrally acting alpha adrenergic agonist

Clonidine and guanfacine have also been very useful in decreasing levels of hyperactivity and in increasing attention and concentration. They are not necessarily as effective as stimulant medications but they are effective in a group of very aroused patients. Side effects are limited to problems with drowsiness and with hypotension.

Intuniv is a long acting formulation of guanfacine.


Venflaxamine (Effexor)

Venflaxamine (Effexor) a mixed serotonin and noradrenergic reuptake inhibiter that has been used in the treatment of difficulties related to concentration, attention and regulation of activity level with some limited success. Recently, Venflaxamine has come under increasing scrutiny because of issues related to possible increased suicidal ideation and suicidal behaviors in children and adolescents taking serotonin reuptake inhibiters. Other problems have included increased irritability and possible increases in blood pressure.


Buproprion (Wellbutrin)

Buproprion (Wellbutrin) is an anti-depressant medication that is sometimes used in the treatment of problems with attention and concentration. Buproprion can be reasonably effective in the reduction of symptoms but must be used with caution in children or adolescents with history of seizures, head injury or bulimia. (This medication has also been included in the list of antidepressants where care as to be given secondary to fears of increased suicidal thoughts or behaviors.)


Tri-cyclic Antidepressants

Tri-cyclic antidepressants have also been used successfully in the treatment of problems with attention, concentration and regulation of activity levels. The tri-cyclics used in children most often include imipramine and nortrityline. They generally have good effectiveness over twenty four hours but they can have troublesome side effects that include a widening of the QRS as measured on EKG. Also they can lead to drowsiness, weight gain, dry mouth and constipation. It is also generally important to check serum levels of these medications while a child is being treated.




Psychiatric Annals 37:7 July 2007 pp 479&480


Mondafanil, amantadine, nemantadine, anticholinesterase inhibitors.

There have been some studies but no definitive work. Generally these have not been found to be helpful


Case Study

17 yo who presents to inpatient hospitalization at a treatment facility for SUD. The patient is acutely suicidal and has attempted suicide with overdose leading to the admission.

Diagnosed with ADHD at age 4. At that point there was a history of severe hyperactivity, inattention, and impulsivity.

Treated initially with Ritalin. Problems persisted. Eventually changed to Adderall, then Concerta, and eventually Dexedrine at age 9 yo. Required very very large doses of Dexedrine. There was a response.


Case Study (cont.)

At age 11 developed symptoms consistent with depression and became suicidal. Treated with Serzone and responded very well. He had a great year.

At age 13 became involved with juvenile court authorities for vandalism.

At age 14 changed to Strattera and did “wonderfully”. It was like a wonder drug according to his mother.

At age 15 parents divorced in very bitter divorce. Patient moved to live with father in another state.


Case Study (cont.)

At age 16 dropped out of school. Began to sell and became involved with

organized crime. Increasing problems with aggression and mood instability. Violence toward girl friend. Involvement with the authorities. First hospitalization for 30 day treatment. Released and rapidly relapsed.

Father disclosed new “information” about patient’s mothere. Patient attempts suicide. Current admission


Questions

What do we need to know?

What is the differential?

Where do we start with treatment?

What are the major issues related to treatment?

What is the prognosis?

Health & Medicine

ADHS Treatment Basics