Drug Treatments for ADHD in Children and Adolescents Dr. Charles Pemberton, Ed.D., LPCC

1. Drug Treatments for ADHD in Children and Adolescents Dr. Charles Pemberton, Ed.D., LPCC

2. Charles Pemberton Ed.D. in Educational Counseling 16 years in Counseling and Mental Health Presented in England, South Africa, Central America, and US. Adjunct Professor – Graduate University of Louisville Undergraduate – IvyTech and KCTCS Private Practice – 80% children and families ADHD Depression Aggression Anxiety Introduction

3. Diagnosis and Identification Types (Dr. Amen) Drug Treatment Tools and Resources Questions Today’s Schedule

4. Complete picture of medications A plan that will work everywhere with everyone What you won’t get today

5. Biological Disorder Neurological – dopamine/norepinephrine Genetic Toxins Head injuries No evidence: Sugar Food additives Allergies Immunizations Causes of ADHD

6. Oppositional Defiance Disorder Conduct disorder Mood Disorder Anxiety Disorder Learning Disorder Tourettes Hx abuse or neglect, multiple foster homes, lead poisoning, Mental Retardation Co morbidity

7. Type 1: Classic ADD Restlessness, hyperactivity, constant motion, troubles sitting still, talkative, impulsive behavior, lack of thinking ahead . Type 2: Inattentive ADD Short attention span (especially about routine matters), distractibility, disorganization, procrastination, poor follow-through/task completion. Types according to Dr. Amen

8. Type 3: Overfocused ADD Worrying, holds grudges, stuck on thoughts, stuck on behaviors, addictive behaviors, oppositional/argumentative. Type 4: Limbic ADD Sad, moody, irritable, negative thoughts, low motivation, sleep/appetite problems, social isolation, finds little pleasure. Types cont’

9. Types cont’ Type 5: Temporal Lobe ADD Inattentive/spacey/confused, emotional instability, memory problems, periodic intense anxiety, periodic outbursts of aggressive behavior seemingly triggered by small events or intense angry criticisms directed at himself for failures and frustrations, overly sensitive to criticism and slights by others, frequent headaches and/or stomachaches, learning difficulties, and serious misperceptions/distortions of people and situations.

10. Type 6: Ring of Fire ADD A ring of overactivity in the brain scan image which surrounds most of the brain is the source of the name for this type of ADD. too many thoughts, very hyper behavior, very hyper verbal expressiveness, a hypersensitivity to light, sound, taste, or touch. Types cont’

11. Type 1: Classic ADD Stimulant medication (Ritalin, Adderall, etc.), a diet with more protein and less carbohydrates, intense aerobic exercise. Type 2: Inattentive ADD Stimulant medication, perhaps stimulating antidepressants (Welbutrin, for example), a diet with more protein and less carbohydrates, intense aerobic exercise. Amen’s Interventions

12. Type 3: Overfocused ADD An antidepressant that has a dual focus on two brain transmitters (seratonin and dopamine) (Effexor, for example), and/or an antidepressant that enhances seratonin (Prozac, Zoloft, Paxil, or others, for example). A stimulant medication may need to be added. A diet with less protein and increased complex carbohydrates will help, along with intense aerobic exercise. Type 4: Limbic ADD An antidepressant that is also stimulating (Effexor or Welbutrin, for example), with a stimulant medication could be added; a balanced diet, and intense exercise. Amen’s interventions

13. Type 5: Temporal Lobe ADD Anticonvulsant medication (Neurontin, Depakote for example), a stimulant could be added; a diet with more protein and less simple carbohydrates. Type 6: Ring of Fire ADD Anticonvulsant medication (Neurontin, Depakote for example, a stimulant medication could be added; sometimes some of the newer, different anti-psychotic medications may help (Risperdal, or Zyprexa); a diet with more protein and less simple carbohydrates. Amen’s interventions

14. Evaluate any child 6 to 12 years of age who shows signs of school difficulties, academic underachievement, troublesome relationships with teachers, family members, peers, and other behavioral problems. Use DSM-IV criteria; these require that ADHD symptoms be present in 2 or more of a child's settings, and that the symptoms adversely affect the child's academic or social functioning for at least 6 months. Requires information from parents or caregivers and a teacher or other school professional regarding core symptoms of ADHD in various settings, age of onset, duration of symptoms, and degree of impairment. Assessment for co-existing conditions: learning and language problems, aggression, disruptive behavior, depression or anxiety. Assessment – Am. Acad. Of Pediatrics

15. No test available Dx by: Observation Rating Scales Vanderbilt Conner’s SNAP Assessment Tools

16. Medication Differences Dosages Timing Side-effects Efficacy Behavior Modification How do we treat ADHD?

17. Methylphenidate Dextroamphetamine Atomoxetene Dexmethylphenidate Antidepressants SSRI’s Tricyclics Anticonvulsives Types of Medications

18. Known as: Ritalin, Ritalin SR, Ritalin LA, Concerta, Metadate ER, Metadate CD, Daytrana Pharmacology: It is a CNS stimulant, which is chemically related to amphetamine Preparations – 5, 10, 20 mg tabs; sustained release 20 mg tabs; LA 20, 30, and 40 mg capsules. The SR tablet should be swallowed and not crushed or chewed. Concerta comes in 18 and 36 mg extended release tablets. Metadate CD 20 mg capsules; Metadate ER 10 – and 20 – mg tabs. Focalin 2.5, - 5-, 10 - mg tabs. Basic Elements of Methylphenidate

19. Half-Life – 3-4 hours; 6-8 hours for sustained release It’s a schedule II controlled substance, requiring a triplicate prescription Pre-Drug Work-Up Blood pressure and general cardiac status baseline and periodic blood counts and liver function tests Weight and growth should be monitored in children Methylphenidate, cont’d

20. Adverse Drug Reactions Nervousness and insomnia; can be reduced by decreasing dose. Cardiovascular – Hypertension, tachycardia, and arrhythmias. CNS – Dizziness, euphoria, tremor, headache, precipitation of tics and Tourette’s syndrome, and rarely psychosis. GI – Decreased appetite, weight loss. Case reports of elevated liver enzymes and liver failure. Hematological –Leukopenia and anemia have been reported Growth Inhibition Methylphenidate, cont’d

21. Similar Side effects Less Upper GI problems Takes approx 1 hour Lasts 2-3 hours after removed Can be split 10, 15, 20, and 30 mg Cannot be shared Daytrana

23. Known as: Adderall, Adderall XR Pharmacology:causes the release of norepinepherine from neurons. At higher doses, it will also cause dopamine and serotonin release Preparations – Adderall 5-, 7.5-, 10-, 12.5-, 15-, 20-, 30-mg tablets; Adderall XR 5-, 10-, 15-, 20-, 25-, 30-mg capsules. Basic Elements of Dextroamphetamine

24. Half-Life – 10-25 hours It’s a schedule II controlled substance, requiring a triplicate prescription Pre-Drug Work-Up Blood pressure and general cardiac status should be evaluated prior to initiating dextroamphetamine. Can precipitate tics Contraindicated in in patients with hypertension, hyperthyroidism, cardiac disease or glaucoma. It is not recommended for psychotic patients ot patients with a history of substance abuse. Weight and growth should be monitored in all children. Dextroamphetamine, cont’d

25. Adverse Drug Reactions Side effects – most common side effects are psychomotor agitation, insomnia, loss of appetite, and dry mouth. Tolerance to loss of appetite tends to develop. Effect on sleep can be reduced by making sure no drug is given after 12 pm. Cardiovascular – Palpitations, tachycardia, increased blood pressure. CNS – Dizziness, euphoria, tremor, precipitation of tics, Tourette’s syndrome, and rarely, psychosis. GI – Anorexia and weight loss, diarrhea, constipation. Growth inhibition Dextroamphetamine, cont’d

27. Adderall XR

28. Known as: Strattera Pharmacology:works via presynaptic norepinepherine transporter inhibition Preparations – 10, 18, 25, 40, and 60 mg capsules . Basic Elements of Atomoxetene

29. Half-Life – approximately 4 hours Not a schedule II controlled substance Clinical Guidelines – Dividing the dose may reduce some side effects Dose reductions are necessary in presence of moderate hepatic insufficiency Atomoxetine should not be used within 2 weeks of discontinuation of a MAO inhibitor. Atomoxetine should be avoided inpatients with narrow angle glaucoma and, it should be used with caution in patients with tachycardia, hypertension, or cardiovascular disease. It can be discontinued without taper. Pregnancy C category. Atomoxetene, cont’d

30. Adverse Drug Reactions Cardiovascular – increased blood pressure and heart rate (similar to those seen with conventional psychostimulant). BI – Anorexia, weight loss, nausea, abdominal pain. Miscellaneous – Fatigue, dry mouth, constipation, urinary hesitancy and erectile dysfunction. Atomoxetene, cont’d

31. Known as: Focalin, Focalin XR Pharmacology:causes the release of dopamine from neurons. Is an isomer of Ritalin. Preparations – Focalin 2.5, 5 ,10-mg tablets; Focalin XR 5-, 10-, 20-mg capsules. Basic Elements of Dexmethylphenidate

32. Half-Life – 2.2 hours It’s a schedule II controlled substance, requiring a triplicate prescription Pre-Drug Work-Up Blood pressure and general cardiac status should be evaluated prior to initiating Dexmethylphenidate. Can precipitate tics Contraindicated in in patients with hypertension, hyperthyroidism, cardiac disease or glaucoma. It is not recommended for psychotic patients or patients with a history of substance abuse. Weight and growth should be monitored in all children. Dexmethylphenidate, cont’d

33. Adverse Drug Reactions Side effects – most common side effects are psychomotor agitation, insomnia, loss of appetite, and dry mouth. Tolerance to loss of appetite tends to develop. Effect on sleep can be reduced by making sure no drug is given after 12 pm. Cardiovascular – Palpitations, tachycardia, increased blood pressure. CNS – Dizziness, euphoria, tremor, precipitation of tics, Tourette’s syndrome, and rarely, psychosis. GI – Anorexia and weight loss, diarrhea, constipation. Growth inhibition Dexmethylphenidate, cont’d

34. Focalin XR

42. Dexadrine Cylert Since marketing in 1975, 13 cases of acute hepatic failure have been reported to the FDA. 11 resulted in death or transplant. Attenade Paxil Wellbutrin Zoloft Trileptal Celexa/Lexapro Effexor Other Medications

43. Side effects Past history Substance abuse Efficacy Onset time Stimulant first line, Strattera second Follow MD When to use, when to change

44. Stimulants still first line defense Look at choice of drug based upon time of release Be aware of study sponsor Addictive nature Subscribe to Medscape Closing Thoughts

45. ADD/ADHD Behavior-Change Resource Kit Teenagers with ADD: A Parents’ Guide www.myadhd.com www.adhdhelp.com www.amenclinic.com www.epocrates.com www.pembertoncounseling.com Tools/Resources

46. American Academy of Pediatrics. Diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. Pediatrics. 2000;105:1158-1170. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. DSM-IV-TR. In: Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence: Diagnostic Criteria for Attention-Deficit/Hyperactivity Disorder. Washington, DC: American Psychiatric Association; 1994:92-93. National Institute of Mental Health. National Institutes of Health. Attention deficit hyperactivity disorder. Available at: http://www.nimh.nih.gov/publicat/helpchild.cfm. Accessed April 19, 2002. U.S. Department of Health and Human Services. Mental Health: A Report of the Surgeon General. Available at: http://www.surgeongeneral.gov/library/mentalhealth/chapter3/sec4.html. Accessed April 19, 2002. Dulcan M. Practice parameters for the assessment and treatment of children, adolescents, and adults with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 1997;369(suppl):855-1215. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. DSM-IV-TR. In: Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence: Diagnostic Criteria for Attention-Deficit/Hyperactivity Disorder. Washington, DC: American Psychiatric Association; 1994:92-93. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. DSM-IV-TR. In: Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence: Diagnostic Criteria for Attention-Deficit/Hyperactivity Disorder. Washington, DC: American Psychiatric Association; 1994:92-93. National Institute of Mental Health. National Institutes of Health. Attention deficit hyperactivity disorder—questions and answers. Available at: http://www.nimh.nih.gov/publicat/adhdqa.cfm. Accessed April 19, 2002. National Institute of Mental Health. National Institutes of Health. Attention deficit hyperactivity disorder—questions and answers. Available at: http://www.nimh.nih.gov/publicat/adhdqa.cfm. Accessed April 19, 2002. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000. Fauman, M. A. (2002). Study Guide to DSM-IV-TR. Washington, DC: American Psychiatric Publishing, Inc. References