Medications for ADHD3

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Information about Medications for ADHD3
Education

Published on February 27, 2008

Author: Veronica1

Source: authorstream.com

Medications for ADHD:  Medications for ADHD Frank W. Gearing MD Harrisonburg Pediatrics, P.C. Harrisonburg, Virginia Common presentation of 3 to 6 year-olds with ADHD:  Common presentation of 3 to 6 year-olds with ADHD Motor restlessness (always on the go) Spills things Insatiable curiosity “Dangerously daring” Vigorous, aggressive play (breaks toys; accidental injuries) Demanding, argumentative Noisy, interrupts Low levels of compliance Common presentation of 6 to 12 year olds with ADHD:  Common presentation of 6 to 12 year olds with ADHD Easily distracted Homework poorly organized, careless errors, often not completed Performing below academic expectations Blurts out answers before question completed (disruptive in class) Interrupts or intrudes on others Difficulties in peer relationships Fails to wait turn in games Often out of seat “Immaturity” Common presentation of 12 to 18 year olds with ADHD:  Common presentation of 12 to 18 year olds with ADHD Sense of inner restlessness Schoolwork disorganized and shows poor follow-through Fails to work independently “Risky” behaviors-sex, drugs, driving Poor self-esteem Poor peer relationships Difficulty with authority figures Medication for ADHD:  Medication for ADHD Goals for this presentation: To leave the participant aware of the complexity of successful management of ADHD. To familiarize the participant with medication options and some rationale to therapy decisions. To encourage a philosophy of treating the whole child within their daily context. ADHD:  ADHD ADHD is a biologic process ADHD is not a disorder of morality ADHD is a behavioral syndrome, not merely a result of unreasonable expectations and a fast paced society. ADHD is a behavior disorder with multiple presentations and multiple possible causes including genetic, brain injury, abnormal brain development, and environmental factors. ADHD involves biochemical messengers Dopamine, Norepinephrine, epinephrine, ? others Neurotransmitters:  Neurotransmitters Research has focused on the prefrontal and frontal cortex areas of the brain controlling behavior and synthesizing thoughts and motor acts into purposeful sequences. Deficits in reasoning, judgment, impulse control and memory account for many symptoms of ADHD ADHD:  ADHD Norephinephrine (NE) and dopamine (DA) are not likely the only neuro- transmitters involved in ADHD, but there is strong evidence that they play an essential role in attention and thinking. Neurotransmitters:  Neurotransmitters Attributing unique and specific behavioral functions to each neurotransmitter is likely too simplistic. Brain structures, neuronal pathways, and neurotransmitters that govern reasoning, judgment, impulse control, and memory are multiple. Effective mental processing is dependent on NE and DA collaborating to facilitate intellectual and emotional functions. Neurotransmitters:  Neurotransmitters NE is critical to reasoning, learning, problem solving, priority setting, organizational thought NE functions in maintaining arousal, regulating excitability related to danger, contributes to memory storage and retrieval DA is involved in motor control, and interacts with NE in the frontal lobe to maintain attention. Neurotransmitters :  Neurotransmitters Psychostimulant actions: Methylphenidate- increases DA by blocking reuptake of DA Amphetamines block DA reuptake and increase production of DA and NE Atomoxetine NE reuptake inhibitor Unknown mechanism increases prefrontal cortex DA Neurotransmitters:  Neurotransmitters Alpha adrenergic 2A Agonists (clonidine, Tenex) increase NE in the prefrontal cortex . Improving working memory, impulsiveness, distractibility. Mimics many effects of NE Histaminic agents increase arousal (Modafanil is prescribed for Narcolepsy). Found effective for ADHD symptoms Modafanil was not approved by FDA. Studies continue or similar medications. Medications for ADHD:  Medications for ADHD Medication Action Methylphenidate Increase DA Amphetamines Increase NE, DA Atomoxetine Increase NE, DA, ? Ser Wellbutrin Increase NE, Serotonin Clonidine Increase NE Tenex Increase NE effect Tricyclics Increase NE, Serotonin Psychostimulants:  Psychostimulants Methylphenidate products (Ritalin) Ritalin (4 hours) Ritalin LA (8-10 hours) Metadate CD (10 hours) Concerta (10-12 hours) Focalin (dexmethylphenidate) (4-6 hours) Focalin XR (10-12 hours) Daytrana (methylphenidate patch) (2- 3hr. after patch removed) Psychostimulants:  Psychostimulants Amphetamine products Dextrostat (4-5 hours) Mixed amphetamine salts Adderall (4-6 hours) Adderall XR (10-12 hours) ADHD Medication Benefits:  ADHD Medication Benefits Improve selective and sustained attention Improve impulse control Improve regulation of activity and arousal Improve memory Improve productivity, accuracy, and organization Improve reinforceability Improve emotional control Medication should not change a person any more than a pair of glasses does. ADHD Medication Side Effects:  ADHD Medication Side Effects Workable Decreased appetite- Stimulants, Strattera Headache- Stimulants, Strattera, Tenex Stomachache- Stimulants, Strattera Insomnia- Stimulants Suicidal thoughts- Strattera Skin rash- Daytrana ADHD Medication Side Effects:  ADHD Medication Side Effects Not Tolerated Personality Change or social withdrawal Excessive Lethargy (Zombie) Liver Injury (Strattera) May be tolerated Tics Seizures Family history of heart disease Rebound from ADHD Medication:  Rebound from ADHD Medication Irritability, hyperactivity and impulsiveness exceeding untreated symptoms As psychostimulants “wear off.” Homework time 5-9 p.m. Increases family stress Often requires short acting stimulant supplement after school hours May suggest need for increased dose or change of medication Homework and Play :  Homework and Play So that medication is working for homework, students do homework immediately after school. Physical activity and play are known to improve focus and attention. Children need time to play, free from activities requiring sustained mental effort. Balancing the child’s needs for play and socialization with parent and school expectations, while protecting the child’s self concept, is a challenge that requires our attention to the details of the child’s routines, interests, and struggles. Medications for ADHD:  Medications for ADHD Prior to initiating medication consider: Proper evaluation and accurate diagnosis Co-morbid conditions that could be the accurate diagnosis Learning disorder Depression Anxiety Adjustment disorders Other: CAPD, SUD, Bipolar, Aspergers, ….. Medications for ADHD:  Medications for ADHD Prior to initiating medication document: Family history of response to medication Prioritized “Target Symptoms” Compliance and Follow-up requirements Plan for coordination of care (counselors, teachers, care providers, parents) Develop structure around TV, computer, video games, caffeine use Target Symptoms:  Target Symptoms Academic or occupational performance Behavior Social and family interactions Self-care Self esteem Safety Interactions with teachers and authorities ADHD Medication Fine Tuning:  ADHD Medication Fine Tuning Considerations in choice of medication Child’s profile- interests, personality traits, social skills, emotional stability Anxiety or depression symptoms Aggressive behavior Other medical diagnoses and medication Sleep patterns Tics Seizures Family dynamics Fine Tuning ADHD Medications:  Fine Tuning ADHD Medications Morning person (runs out of mental energy in afternoon) Avoid difficult classes in afternoon Encourage afternoon physical activity Homework may require supplemental medication after school Rebound symptoms may be more likely without supplemental medication Fine Tuning ADHD Medications:  Fine Tuning ADHD Medications Afternoon person (hard to get started in morning) Schedule difficult classes in mid day Encourage morning physical activity Evaluate sleep hygiene at each visit May require short acting stimulant in morning in addition to sustained release preparation ADHD Medication Fine Tuning:  ADHD Medication Fine Tuning Morning person Concerta releases 22% of medication in first hour with slow release of remaining 78% over 10-12 hours Metadate CD releases 30% of medication in first hour with slow release of remaining 70% over 8-10 hours Daytrana constant absorption by the skin; offers flexibility for wear time. Adderall XR 50% immediate release and 50% release after 4 hours ADHD Medication Fine Tuning:  ADHD Medication Fine Tuning Afternoon person Ritalin LA releases 50% immediately and 50% 4 hours later Focalin XR releases 50% immediately and 50% 4 hours later Adderall XR 50% immediately and 50% 4 hours later Concerta or Metadate plus short acting methylphenidate Daytrana eliminates pill struggles. ADHD Medication Fine Tuning:  ADHD Medication Fine Tuning ADHD with depressive or anxious symptoms or learning disorders may respond best to Strattera Strattera less effective for hyperactivity Strattera may improve early morning and evening behavior. Strattera can be used along with stimlants SSRI’s are well tolerated and can be used in conjunction with stimulants for more depressed or anxious patients ADHD Medication Fine Tuning:  ADHD Medication Fine Tuning Aggressive behaviors, tics, and disturbed sleep may respond to Clonidine or Tenex New research indicate benefits from Tenex for impulsive/inattentive symptoms over time. Tenex beneficial in ADHD patients with PTSD. Insomnia may respond to Melatonin, Clonidine, or Remeron Black Box Warnings:  Black Box Warnings Stimulants Risk of sudden death 25 deaths and 54 cardiovascular problems in adults and children between 1999 and 2003 Report does not indicate the drugs were responsible for the deaths Screen all patients for high risk conditions including structural heart defects. Some physicians require consent. Strattera Increased suicidal thoughts Not increase in suicide attempts Monitoring is recommended. Black Box Warning:  Black Box Warning Antidepressants Increased suicidal thoughts Obtain informed consent Signed by parent and child over age 14 yr. Weekly visits for 4 weeks then every other week visits for 4 weeks Consider required counseling and regular communication with counselor. Concerns Associated with Stimulants:  Concerns Associated with Stimulants Growth: Area of controversy Some studies show modest reduction in rate of growth Adjustments in medication dose and/or choice may be necessary Reduced impact after first 3 months (when taken daily) Catch-up growth even with continued stimulant treatment Exception may be child < 6 years Concerns Associated with Stimulants:  Concerns Associated with Stimulants Diversion- Selling or giving drug to others New investigational drug lisdexamfetamine (Vyvance) is a prodrug of dexamphetamine with rate limited metabolism and has reduced risk of abuse, diversion, and overdose. Untreated ADHD has twice the risk for substance abuse, with earlier onset, and less likelihood to recover as an adult 25% of patients seeking SUD treatment also have ADHD Effective management of ADHD significantly decreases risk for substance abuse ADHD For a Lifetime:  ADHD For a Lifetime Personal safety Children with ADHD have 50% more bike accidents and 33% more ED visits School- Higher rates of expulsion and drop out for children with ADHD Driving ADHD - 2-4 times more likely to have an auto accident with 3 times more monetary damage and 3 times greater likelihood of serious injury ADHD - twice as many speeding tickets The privilege to drive must be tied to medication compliance Stress on Families :  Stress on Families Employment stability Parents of children with ADHD have greater absenteeism from work Parents of children with ADHD are less productive in the work place Untreated adults with ADHD have poor employment records Vocational aptitude testing beneficial for teens with ADHD seeking areas of likely success Interpersonal relationships Marriage/divorce- 3-5 times greater parental divorce or separation in families with a child with ADHD Monitoring ADHD Management:  Monitoring ADHD Management Monthly weight, height, and blood pressure for six months followed by 3-6 month interval check is most effective follow up routine. Appetite, sleep, energy, mood changes Worries, rituals, depression, thoughts of suicide Social, school, and family interactions Recreation and sports involvement Be specific and detailed Monitoring ADHD Medications:  Monitoring ADHD Medications School performance Specify which subjects are problematic and whether it is homework, tests, class work If improvements: what interventions have succeeded Share successful interventions with other teachers Medications for ADHD:  Medications for ADHD When there is a sudden deterioration in daily functioning after a long period of stability it is most often not an issue of medication failure. Consider other explanations such as changes in family dynamics, changes in peer relations, pregnancy, drug use, etc. Why Treat ADHD:  Why Treat ADHD Children with ADHD are impacted over a lifetime by: Parents who do not understand, are frustrated and feel guilty Teachers who may label a child as lazy, slow, or bad. Rejection by peers because of poor social skills. Spouse or boss who are exasperated by lack of organization, forgetfulness, and inability to complete tasks. Risks of comorbid conditions Medications for ADHD:  Medications for ADHD Reasons for treatment failure Untreated parent with ADHD Lack of family and patient education of about ADHD leading to lack of understaning about the problem and the management plan Undiagnosed comorbid condition Lack of recognition for success 80% of interactions for children with ADHD who are not stabilized are negative. Reinforce the positive. Catch them doing well. What’s Next?:  What’s Next? Vyvance – Adderall patch has FDA approval and will be available summer 07. Sustained release Tenex Research on use of Antihistaminic agents like Modafinil Research on Alzheimer’s medication use in ADHD

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