ADHD 101


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This is a small presentation giving basic information about ADD or ADHD and the causation, and various ways in which we can help the children with ADHD. This presentation is primarily meant to help parents who have a child suffering from ADHD, and shall be helpful in decision making for them. Towarrds the end I have tried to answer the frequently asked questions that parents usually have for me.

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ADHD 101

  1. 1. ADHD-101 ADHD 101: All the information you need. Pallav Pareek M.D.
  2. 2. Disclaimer <ul><li>This information is essentially for the parents who are trying to know what ADHD is, its causation, and possible ways to treat it. </li></ul><ul><li>This may also be useful for medical students, if this is their first psychiatric rotation and they have not read about this before. </li></ul><ul><li>Not to be used for any medical/legal purposes </li></ul>
  3. 3. What is ADHD <ul><li>As the full name for the abbreviation is A ttention D eficit H yperactivity D isorder. This is a self explanatory term if we look closely at it: First two words are attention deficit ; meaning the child is inattentive, seems lost , does not follow through on the instructions, and the second part is hyperactivity ; which includes hyperactivity and impulsivity. An example would be a child who runs up and down, cannot sit still, is bouncing off the walls, & disorder meaning that this is a disorder and not just “an energetic child” as your grandmother (or for that matter any other family relative) suggested. The child with ADHD can present with three subtypes depending on which symptoms are predominant: </li></ul><ul><li>- Predominantly inattentive, </li></ul><ul><li>- Predominantly hyperactive type, or </li></ul><ul><li>- Combined type where both types of symptoms are present. </li></ul>
  4. 4. DSM Criteria <ul><li>The Diagnostic and Statistical Manual of Mental Disorders ( DSM ) is the bible used by the psychiatrists here is USA and many other parts of the world. It is published by the American Psychiatric Association & defines standard criteria for the classification of mental disorders. </li></ul><ul><li>In the next slide(s) we shall see the DSM criteria for ADHD </li></ul>
  5. 5. DSM-IV* Criteria for ADHD <ul><li>  1. Either A or B: Six or more of the following symptoms of inattention have been present for at least 6 months to a point that is inappropriate for developmental level: </li></ul><ul><li>A: Six or more of the following symptoms of inattention have been present for at least 6 months to a point that is inappropriate for developmental level: Inattention </li></ul><ul><ul><li>Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities. </li></ul></ul><ul><ul><li>Often has trouble keeping attention on tasks or play activities. </li></ul></ul><ul><ul><li>Often does not seem to listen when spoken to directly. </li></ul></ul><ul><ul><li>Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions). </li></ul></ul><ul><ul><li>Often has trouble organizing activities. </li></ul></ul><ul><ul><li>Often avoids, dislikes, or doesn't want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework). </li></ul></ul><ul><ul><li>Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools). </li></ul></ul><ul><ul><li>Is often easily distracted. </li></ul></ul><ul><ul><li>Is often forgetful in daily activities. </li></ul></ul>
  6. 6. DSM-IV* Criteria for ADHD (contd:) <ul><li>B. Six or more of the following symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level:     Hyperactivity </li></ul><ul><li>  </li></ul><ul><ul><li>Often fidgets with hands or feet or squirms in seat when sitting still is expected. </li></ul></ul><ul><ul><li>Often gets up from seat when remaining in seat is expected. </li></ul></ul><ul><ul><li>Often excessively runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless). </li></ul></ul><ul><ul><li>Often has trouble playing or doing leisure activities quietly. </li></ul></ul><ul><ul><li>Is often &quot;on the go&quot; or often acts as if &quot;driven by a motor&quot;. </li></ul></ul><ul><ul><li>Often talks excessively. </li></ul></ul><ul><li>  </li></ul><ul><li>Impulsivity </li></ul><ul><ul><li>Often blurts out answers before questions have been finished. </li></ul></ul><ul><ul><li>Often has trouble waiting one's turn. </li></ul></ul><ul><ul><li>Often interrupts or intrudes on others (e.g., butts into conversations or </li></ul></ul>
  7. 7. DSM-IV* Criteria for ADHD (contd:) <ul><li>2. Some symptoms that cause impairment were present before age 7 years. </li></ul><ul><li>3. Some impairment from the symptoms is present in two or more settings (e.g. at school/work and at home). </li></ul><ul><li>4. There must be clear evidence of clinically significant impairment in social, school, or work functioning. </li></ul><ul><li>5. The symptoms do not happen only during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder. The symptoms are not better accounted for by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder). </li></ul>
  8. 8. DSM-IV* Criteria for ADHD (contd:) <ul><li>Based on these criteria, three types of ADHD are identified: </li></ul><ul><li>IA. ADHD, Combined Type : if both criteria IA and IB are met for the past 6 months </li></ul><ul><li>IB. ADHD, Predominantly Inattentive Type : if criterion IA is met but criterion IB is not met for the past six months  </li></ul><ul><li>IC. ADHD, Predominantly Hyperactive-Impulsive Type : if Criterion IB is met but Criterion IA is not met for the past six months.   </li></ul><ul><li>* Diagnostic And Statistical Manual (for Mental Health disorders) </li></ul>
  9. 9. What did the above 5 slides teach us? <ul><li>Without going into the details of the DSM checklist it can be said that children usually fall into three categories, they can have more inattentive symptoms, more hyperactive-impulsive symptoms are combined type where they have all of the above mentioned. </li></ul><ul><li>But they are still variants of ADHD, and would still classify as having ADHD </li></ul>
  10. 10. IS ADD and ADHD the same? <ul><li>Do you notice a difference in two pictures on the side? </li></ul>
  11. 11. IS ADD and ADHD the same? <ul><li>If you did not notice any difference in the two pictures: your money is right where the answer is, the only difference in those two pictures is the written words. </li></ul><ul><li>Third edition of the DSM: DSM III described the illness as ADD </li></ul><ul><li>With the DSM –IV the term ADHD was coined, to encompass more symptoms, and be more descriptive of the illness </li></ul><ul><li>Bottom-line is ADD and ADHD are the different names for the same condition. </li></ul>
  12. 12. Is ADHD genetic? <ul><li>Unfortunately we do not have the right answer for this at the current point in time. The monozygotic and dizygotic concordance of this disease are 50-80% and 25-35% respectively. In simple language this means if your identical twin (monozygotic, or meaning you both share the same genes in every possible way) had ADHD, still there is only 50% chance that you might have ADHD. This means there are more than genetic influences, which could include the risks from the environment. So in simple terms: this is work under a lot of research at this time, and we don't know what causes ADHD, but there is a heavy influence of genetics in this. </li></ul>
  13. 13. Etiology (what causes ADHD?) <ul><li>Genetic </li></ul><ul><li>Of course there is a big factor , if your parents had ADHD there is a good 50% chance of you having the same </li></ul><ul><li>There are two “chemicals in the brain” or neurotransmitters: viz dopamine and norepinephrine, whose amounts are not right and cause ADHD symptoms </li></ul>
  14. 14. What Causes ADHD? <ul><li>So as I have previously mentioned the exact causation is not known but a plausible hypothesis is a malfunction of the CSTC (cortico-striato-thalamo-cortical) circuits. This CSTC essentially are brain circuits which have dopamine as a main neurotransmitter and plays a big role in the regulation of information/stimulation that our brain receives, by filtering unwanted stimulation for the brain. For example if we are reading a book/news-paper we are usually able to ignore the trivial sounds and other click and clack happening around us. But when a child with ADHD listens or happens to experience a very minor stimulus, they do respond to it (because CSTC is not filtering these stimuli) hence seem bored, “switch tasks” and “can’t concentrate”. Similarly such dysregulation of these loops causes hyperactivity and impulsivity, often seen in kids with ADHD. </li></ul>
  15. 15. Are there any environmental factors? <ul><li>There is a lot of debate about environment in the causation of ADHD, but this certainly is a big factor. (though not completely understood) Examples of environmental factors could be (but not limited to) </li></ul><ul><li>Maternal smoking/alcohol during pregnancy </li></ul><ul><li>Hypoxia (oxygen deprivation) at time of birth </li></ul><ul><li>Injury to the newborn brain </li></ul><ul><li>Jaundice (hyperbilirubinemia) at birth </li></ul><ul><li>& in addition there is a big genetic influence on ADHD causation as we discussed above </li></ul>
  16. 16. Is Medicine the only answer?? <ul><li>If you as a parent are at a stage where you have been trying to find solutions online, it would be safe to assume that the symptoms are causing some form of occupational (meaning school) or social (behavior at home or in other social situations) dysfunction. </li></ul><ul><li>At this point in time scientific literature does not support the fact that any other intervention might be better than psychopharmacological interventions. </li></ul><ul><li>In Plain simple language: Medicine may be the best choice </li></ul>
  17. 17. What are the medicine choices? <ul><li>In a broad categorization we have three form of medicines </li></ul><ul><li>Psycho-stimulants or Stimulants </li></ul><ul><li>Alpha Agonists </li></ul><ul><li>Non Stimulant ADHD medications </li></ul><ul><li>Other alternatives </li></ul>
  18. 18. Other Alternative medications <ul><li>Buproprion: Wellbutrin® </li></ul><ul><li>Imipramine: Tofranil® </li></ul><ul><li>Nortriptyline: Pamelor® </li></ul><ul><li>These are the antidepressant medications that have been variously used /indicated in medical literature to have some effect on ADHD. </li></ul><ul><li>Mostly used as 4 th line drugs </li></ul><ul><li>In a NUTSHELL: Not as effective as the traditional ADHD medications </li></ul>
  19. 19. Strattera: Non-stimulant medication <ul><li>Atomoxetine aka Strattera: This is a medication that was developed as an antidepressant by Eli lilly, but did not show the desired affect as an antidepressant. </li></ul><ul><li>This is commonly used a third line (you can say second line) agent </li></ul><ul><li>This is not a stimulant medication, and many parents choose this over the stmulants </li></ul>
  20. 20. Strattera® <ul><li>Available as 10, 18, 25, 40, 60, 80 & 100 mg caps </li></ul><ul><li>Less abuse potential (less habit forming) </li></ul><ul><li>Severe liver damage in some reported cases have lead to a black-box warning by the FDA </li></ul><ul><li>Most common side effects: dry mouth, tiredness, irritability, nausea, decreased appetite, constipation, dizziness, sweating, dysuria (painful urination) </li></ul>
  21. 21. Alpha Agonists: Clonidine & Guanfacine <ul><li>These medications were initially discovered as blood pressure medications. </li></ul><ul><li>Effective add-on’s for ADHD which is not responding to stimulants alone. </li></ul><ul><li>The 2 drugs are like sisters with more similarities than differences, which we shall discuss in later slides </li></ul><ul><li>Both the above medications are being increasingly used and successfully so for the treatment of ADHD and Tics and more so when both these conditions are present concomitantly </li></ul>
  22. 22. Clonidine <ul><li>It is available with the brand names Catapres, Kapvay, Nexiclon etc. </li></ul><ul><li>Initially this was introduced in 1950’s as an antihypertensive (blood pressure) medication </li></ul><ul><li>Since then it has found many uses including but not limited to neuropathic pain, opioid detoxification, sleep hyperhidrosis, and to treat anxiety and panic disorder </li></ul><ul><li>It is FDA approved for use for ADHD </li></ul><ul><li>Valuable medication for TICS </li></ul>
  23. 23. Clonidine <ul><li>Available as 0.1,0.2 & 0.3 mg tabs </li></ul><ul><li>Common side effects include: lightheadedness, dry mouth, dizziness, constipation, hypotension (low blood pressure) </li></ul><ul><li>A common side effect is it causing sedation, and can be valuable if sleep is an adjunct problem for your child </li></ul><ul><li>Parents should be conscious that since this medication causes drop in blood pressure, thus it should be used regularly, and before discontinuation you should always discuss with your doctor . </li></ul>
  24. 24. Guanfacine <ul><li>Available as 1 and 2 mg tablets </li></ul><ul><li>This is available as a generic </li></ul><ul><li>Brand name Tenex® and an extended release form called Intuniv ® </li></ul><ul><li>It is similar in mechanism of action to clonidine </li></ul><ul><li>Causes less sedation </li></ul><ul><li>Also used in TICS with good success rates </li></ul>
  25. 25. STIMULANTS <ul><li>Also known as psychostimulants </li></ul><ul><li>First line of treatment for ADHD </li></ul><ul><li>Two broad categories of Stimulants are methylphenidate and amphetamine variants </li></ul><ul><li>Most (all) of the stimulant medications used for ADHD will fall into one of these categories. </li></ul><ul><li>These medications are very effective, and if it is to work in your child, you will notice the difference after the first dose itself. </li></ul>
  26. 26. Amphetamine Preperations
  27. 27. Methylphenidate Preperations
  28. 28. Stimulants continued <ul><li>Most of the preparations of stimulants will come from one of these families of stimulants </li></ul><ul><li>Common Side effects: </li></ul><ul><li>Appetite suppression, growth delay </li></ul><ul><li>Problems with sleep (insomnia) </li></ul><ul><li>Blood pressure and heart rate changes </li></ul><ul><li>End-of-dose withdrawal/rebound </li></ul>
  29. 29. Commonly asked questions In the next few slides I will try to answer some questions that parents usually have regarding the stimulant medications when they meet with me as a child psychiatrist. Of course this is all my opinion, so please do discuss with your psychiatrist /pediatrician before agreeing or disagreeing with any of these, as the medication has to be individualized according to each patient.
  30. 30. Will it limit my child’s height? <ul><li>This indeed is a concern, and it is true that the stimulants might cause some growth suppression. But the good news is this is a reversible effect, which means as soon as the child is off the stimulants, they are more than likely to fall on the growth curve they were supposed to be at. </li></ul>
  31. 31. My child does not feel hungry!! <ul><li>True stimulants will cause appetite suppression. So what can you do? </li></ul><ul><li>Give them more energy dense foods </li></ul><ul><li>You can be more liberal with the meal timings </li></ul><ul><li>Always give a heavy breakfast before the morning dose of the stimulant </li></ul><ul><li>Try to work around the foods of the child’s choice </li></ul>
  32. 32. Can stimulants cause sudden death? <ul><li>There have been a lot of debate about the stimulants and the possibility of sudden cardiac events leading to death </li></ul><ul><li>Who should be concerned? </li></ul><ul><li>If your child has a documented heart problem, in which case a clearance from a cardiologist might be needed </li></ul><ul><li>If there is a strong family history of cardiac illness causing premature deaths, please make sure you mention this to your child psychiatrist. </li></ul>
  33. 33. Can stimulants cause sudden death? Contd: <ul><li>And as I mentioned there has been a lot of debate in the lay press(as opposed to scientific press), and media over the last decade or more. </li></ul><ul><li>But these arguments did not hold much water, and the stimulants have proved year after year their record as a safe medication choice. The scientific literature does not report any significant increase in any such events. (if need be please email me at [email_address] , and I will be more than happy to send you the supporting literature) </li></ul>
  34. 34. Will the doctor need to do an EKG before starting a stimulant? <ul><li>NO </li></ul><ul><li>That’s a simple answer, but the details of it are, that none of the professional organizations including American Academy of Pediatrics, do not recommend an EKG unless your child is in the high risk categories I mentioned above </li></ul>
  35. 35. My family does not believe in medications <ul><li>Very well: I have had this argument from many a parent saying “My parents never gave me any meds and I turned out fine” </li></ul><ul><li>I do not have any problem against that, but all I ask them is “your parents never took you to a physician to ask what to do” and “Your parents did not have a phone that could be carried in the pocket, much less email somebody” </li></ul>
  36. 36. Can this argument be won???? <ul><li>A lifetime can be spent with parents who do not believe in medications. But it’s akin to saying “my great-grand-father travelled in a bullock-cart or horse-cart and why does my kid need a gasoline driven car to be transported” . So this argument can never be won. </li></ul><ul><li>But all I can say is that the world is becoming increasingly competitive, and the demands are increasing mile a day, and it will not be fair to put out a child in that race with other kids, when he has a lot of difficulty in focusing and concentration, without any fault of his. Because it’s just neurochemicals which are certainly out of that little kid’s control. </li></ul>
  37. 37. Can we use Therapy instead of medications???? <ul><li>Unfortunately NO </li></ul><ul><li>The scientific literature clearly tells us that there is no therapy which has turned out to be superior to any medication choices in the hundreds of randomized controlled trials. </li></ul><ul><li>Therapies may be tried in conjunction with medications to give the best benefit. </li></ul>
  38. 38. I have tried to make this presentation for the frequently asked questions, and is to help parents with the decision making for their children with ADHD. If this presentation does not answer any questions please feel free to email me at [email_address] . Within the limits of my time commitments I will try my best t answer questions that you may have
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