What Teachers Need to Know About ADHD Medications

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  • QEEG - Quantitative ElectroencephalographyEP - Evoked PotentialsSPECT – Single Photon Emission Computed TomographyMRI - Magnetic Resonance ImagingAltropane – small molecule that binds with extremely high affinity and specificity to dopamine transporters
  • What Teachers Need to Know About ADHD Medications

    1. 1. WHAT TEACHERS NEED TO KNOW ABOUT ADHD MEDICATIONS 1
    2. 2. CREDITS Attention-Deficit/Hyperactivity Disorder (ADHD) At the Leading Edge Program Directors:Emmett Francoeur, MD, FRCPC Samuel Chang, MD, FRCPC Grazyna Jackiewicz, MD, FRCPCAssociate Professor, Clinical Associate AssistantMcGill University Professor, University of Calgary Professor, Pediatrics, McMasterDirector, Child Development Director, Adolescent Substance UniversityProgram, McGill University Abuse & Psychiatric Disorders Clinic Consulting Pediatrician inHealth Center Psychiatrist, Foothills Medical Developmental/BehaviouralWestmount, Quebec Centre Pediatrics, American Board Certified Calgary, Alberta Chedoke Developmental/ Behavioural Clinic, Hamilton, Ontario Private Practice, Niagara Falls, Ontario
    3. 3. ASSUMPTIONS• Co Morbidities• Prevalence• Causes• Symptoms• Assessment 3
    4. 4. SOCIETAL IMPORTANCE• Prevalence• Developmental Sequencing• Economics• Multijurisdictional Agency Involvement• Multimodal Management• Prevention 4
    5. 5. ADHD is Most Likely Caused by a Complex Interplay of Factors Neuroanatomic Genetic origins Neurochemical ADHD Environmental factors CNS insultsSwanson JM, et al. Mol Psychiatry. 1998;3(1):38-41. Swanson JM, et al. Lancet. 1998; 351(9100):429-33. Milberger S, et al. Biol Psychiatry. 1997;41(1):65- 75. Castellanos FX, et al. Arch Gen Psychiatry. 1996;53(7):607-16. 5
    6. 6. ADHD Impacts Domains of Function Difficulty With: Before School After School Bedtime School • Waking up • Lower grades • Sports/Clubs • Bedtime prep • Getting ready for • Lack of focus • Homework • Settling down school • Disruptive • Risky behavior and falling asleep • Struggling • Difficulty with and injuries excessively friendships • Sitting through dinner with parents • Family interactionsBarkley RA, et al. J Am Acad Child Adolesc Psychiatry. 1990;29(4):546-57. Barkley RA. J Clin Psychiatry. 2002;63(Suppl 12):S10-5. DuPaul GJ, et al. J Am Acad Child Adolesc Psychiatry. 2001;40(5):508-15. Greenhill LL. J Clin Psychiatry. 1998;59(Suppl 7):S31-41. Weiss G, et al. J Am Acad Child Psychiatry 6 1985;24(2):211-20.
    7. 7. ADHD Impacts Social Functioning Problems • Problems with the justice system • Family conflicts • Early and impulsive sexuality + ADHD • Tobacco and substance abuse • Accidents and injuries • Interpersonal difficulties • School and professional difficulties American Academy of Pediatrics. Pediatrics. 2000:105(5);1158-70. Barkley RA, et al. Clinical Child and Family Psychology Review. 2002;5(2):89-111.Barkley RA. In: Barkely RA, ed. Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment, Third Edition. New York; Guilford, 7 2006.
    8. 8. Evidence for Frontal Lobe Deficits•Deficits on Executive Function Tests•Less Frontal Electrical Activity (QEEG, EEG, EP)•Reduced Blood Flow to Frontal and Striatal Regions(SPECT; Altropane Uptake)•Diminished Frontal and Striatal Metabolic Activity(PET and fMRI)•Smaller Frontal-Basal Ganglia-Cerebellar Areas (MRI) 8
    9. 9. Development and Progressive Cortical Cell Density 9
    10. 10. Executive Functions Often Impaired in ADHD Executive FunctionsOrganizing Focusing, Regulating Managing Utilizing Monitoringprioritizing, sustaining alertness, frustration working and self- and focus, and sustaining And memory regulating activating shifting effort, and modulating And action to work focus to processing emotions accessing tasks speed recall 1. 2. 3. 4. 5. 6.Activation Focus Effort Emotion Memory Action Brown TE. 2001. Manual for Attention Deficit Disorder Scales for Children and Adolescents. 10
    11. 11. Clinical Presentation of ADHD in Adolescents ADHD Symptoms in AdolescentsMay have a sense of inner Procrastinates and displaysrestlessness rather than hyperactivity disorganized school work with poor follow-throughFails to work independently Poor peer relationshipsPoor self-esteemInability to delay gratification Specific learning disabilitiesBehaviour not usually modified by Engages in ―risky‖ behaviourreward or punishment (speeding, unprotected sex, substance abuse)Apparent disregard for own safety Difficulties or clashes with authority(injuries and accidents) Greenhill LL. J Clin Psych. 1998;59(Suppl 7):31-41. 11
    12. 12. Persistance of Disorder •Symptoms decrease somewhat with age •Adolescence: (Based on Parent reports) •50% persistence to adolescence (1970-80s) •70-80% in modern DSM studies (1990s onward) •Young Adulthood (age 20-26) (Barkley et al. 2002) •Depends on who you ask (self vs. parents) •3-8% Full disorder (self-report using DSM III R •46% Full disorder (parent reports using DSM III R) •12% - Using 98th percentile (+2SDs; self-report) •66% - Using 98th percentile (parent report) •Parent reports have greater veracity—they correlate more highly with various domains of major life activities than do self reports •85-90% remain functionally impairedBarkley RA. 2003. Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment 12
    13. 13. Role of teachers• Observer• Reporter (report cards)• Manager• Parent liaison• Health Care liaison• Monitor 13
    14. 14. ADHD Management Goals• Treat ADHD throughout the lifespan• Treat symptoms throughout the full day in multiple areas of a patient‘s daily life  No longer sufficient to treat during the school day or work hours• Develop collaboration between home and schoolConnor DF. In: Barkley RA, ed. Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment, Third Edition. New York; Guilford, 2006. Canadian Attention Deficit Hyperactivity Disorder Resource Alliance (CADDRA): Canadian ADHD Practice 14 Guidelines, First Edition. Toronto, ON; CADDRA, 2006.
    15. 15. ADHD Management Strategies• Psychoeducation  Give local resources, written material and web based resources• Psychosocial interventions  Classroom intervention, family counselling, support groups• Medications  Mainstay of treatment, single most effective intervention, safe, effective and non addictive  Not for children less than 6 years old (certain exceptions apply)Canadian Attention Deficit Hyperactivity Disorder Resource Alliance (CADDRA): Canadian ADHD Practice Guidelines, First Edition. Toronto, ON; CADDRA, 2006. 15
    16. 16. MTA Study: Objective and DesignObjective: To compare the long-term efficacy of pharmacotherapy,behavioral therapy, and combination therapy in the treatment of ADHD. Medication management (primarily methylphenidate)579 ChildrenADHD, Combined typeAge Range: 7-9.9 years Behavioral treatmentRandomly assigned14-month study Combination treatment: medication and behavioral therapy Routine Community Care MTA Cooperative Group. Arch Gen Psych. 1999;56:1073-1086. 16
    17. 17. MTA RESULTSA 14-Month Randomized Clinical Trial of Treatment Strategies for Attention-Deficit/Hyperactivity Disorder. The MTA Cooperative Group 17ARCH GEN PSYCHIATRY/VOL 56, DEC 1999
    18. 18. MTA Study: Conclusions• Combined treatment and medication management were more effective than behavioral treatment and community care in reducing ADHD core symptoms:  Inattention  Hyperactive-impulsive behavior• Patients in the combined treatment group experienced: 1. No significant difference in core ADHD symptoms vs. those in the medication management group 2. Improvements in core ADHD symptoms at a lower dose than patients in the medication management group 3. Modest advantages in non-ADHD symptoms and positive functioning outcomes vs. patients in the medication management group MTA Cooperative Group. Arch Gen Psych. 1999;56:1073-86. 18
    19. 19. Medication Selection Considerations• Earlier medication response• Desired duration of action• Patient and parent preference of medication• Age of patient• Side effect profile• Efficacy of response• CostCanadian Attention Deficit Hyperactivity Disorder Resource Alliance (CADDRA): Canadian ADHD Practice Guidelines, First Edition. Toronto, ON; CADDRA, 2006. 19
    20. 20. Plasma Levels and Therapeutic Effect t½ 20
    21. 21. Concerta – OROS**Osmotic-controlled Release Oral delivery System 21
    22. 22. Concerta and Ritalin Plasma Levels 22
    23. 23. Biphentin (similar for Adderall XR) 23
    24. 24. Vyvanse, Adderall XR: Numbers Test 24
    25. 25. ADHD Therapeutic Options Two Main Classes of Medication Stimulant Non-stimulant Methylphenidate • Ritalin® Atomoxetine • Concerta® • Strattera® • Biphentin® Amphetamines • Dexedrine® Spansule • Adderall® XR • Vyvanse ®Canadian Attention Deficit Hyperactivity Disorder Resource Alliance (CADDRA): Canadian ADHD Practice Guidelines, First Edition. Toronto, ON; CADDRA, 2006. 25
    26. 26. Mechanism of Action of ADHDMedications Stimulant Atomoxetine NorepinephrinePresynaptic neuron Presynaptic neuron Dopamine Norepinephrine reuptake pump Dopamine reuptake pump STM Stimulant A AtomoxetinePostsynaptic neuron Postsynaptic neuron 26
    27. 27. 1st Line Medications for ADHD Simple (Children) FIRST LINE AGENTS – Long-acting preparationsBrand Name Dosage Starting Titration Schedule Every 7 Maximum daily(Generic) Form Dose days* (up to 40 kg child) Product CADDRA Product CADDRA Monograph Board Monograph BoardAdderall® XR 5, 10, 15, 20, 10 mg qam ↑5 -10mg ↑5 -10mg 30 mg 30 mg(amphetamine mixed 25, 30 mg capsalts)Concerta® 18, 27, 36, 54 18 mg qam ↑18 mg ↑18 mg 54 mg 72 mg(methylphenidate HCl) mg tabStrattera® * 10, 18, 25, 40, 0.5 0.8 mg/kg/d at wk 3 Same Lesser of 1.4 mg/kg(atomoxetine HCl) 60 mg cap mg/kg/d 1.2 mg/kg/d at wk 5 Same /day or 60 mg/dayBiphentin® 10, 15, 20, 30, 10-20 mg ↑ 10 mg ↑ 10 mg 60 mg 60 mg(methylphenidate HCl) 40, 50, 60 mg qam capVyvanse ® 20, 30, 40, 50, 20-30 mg By clinical ↑ 10 mg 60 mg 60 mg(lisdexamfetamine 60 qam discretionDimesylate) mg tab *atomoxetine every 10 days; clinicians may opt to titrate every 14 days (practicality) Canadian Attention Deficit Hyperactivity Disorder Resource Alliance (CADDRA): Canadian ADHD Practice Guidelines, Third Edition. Toronto, ON; CADDRA, 2011. 27
    28. 28. 2nd Line / Adjunctive Medications for ADHD Simple (Children) SECOND LINE/ADJUNCTIVE AGENTS – Short-acting & moderate-acting preparationsBrand Name Dosage Starting Titration Schedule Maximum daily (up to(Generic) Form Dose Every 7 days 40 kg child) CADDRADexedrine® 5 mg tab 2.5 – 5 mg q ↑2.5 -5 mg 40 mg 20 mg(dextro-amphetamine am and q noon (add q4pm dose)sulphate)Dexedrine® Spansule* 10, 15 mg 10 mg q am ↑10 mg 40 mg 30 mg(dextro-amphetamine capsulphate)PMS® or Ratio® - 5, 10, 20 mg 5 mg q am and ↑5 mg 60 mg 60 mgmethylphenidate tab q noon (add q4pm dose)Ritalin® 10, 20 mg tab 5 mg b.i.d. to ↑5 - 10 mg 60 mg 60 mg(methylphenidate HCl) t.i.d. (add q4pm dose)Ritalin® SR† 20 mg tab 20 mg q am ↑20 mg 60 mg 60 mg(methylphenidate HCl) (add p2pm dose)*Dexedrine® Spansule may last 6-8 hours†Ritalin® SR may help cover the noon period but clinical experience suggests an effect similar to short-acting preparations Canadian Attention Deficit Hyperactivity Disorder Resource Alliance (CADDRA): Canadian ADHD Practice Guidelines, Third Edition. Toronto, ON; CADDRA, 2011. 28
    29. 29. 3rd Line Medications for ADHD Simple (Children) THIRD LINE AGENTS - Off-label treatments for ADHD used in treatment failure Titration Maximum dailyBrand Name Dosage Starting Schedule (up to 40 kg(Generic) Form Dose Every 7 days child)Apo®-imipramine* 10, 25, 50, 75 25 mg ↑25 mg 150 mg mg tabWellbutrin® SR 100, 150 mg 100 mg qam Add 100 mg qhs 200 mg(bupropion) tab*Tofranil is not recommended due to inadequate dose forms. Sometimes imipramine is used if mood problems andADHD symptoms coexist. Imipramine is metabolized to desipramine which is an effective noradrenergic agonist.Canadian Attention Deficit Hyperactivity Disorder Resource Alliance (CADDRA): Canadian ADHD Practice Guidelines, First Edition. Toronto, ON; CADDRA, 2006. 29
    30. 30. Benefits• Attention Span  Reduced distractibility, improved concentration  Improved organizational skills• Activity levels  Reduced restlessness, fidgeting, hyperactivity• Impulse control  Improved patience  Reduced verbal and physical impulsive actions  Reduced frequency and intensity of emotional reactivity 30
    31. 31. Adverse Effects• Reduced appetite, potential weight loss• Insomnia, difficulty to awaken in a.m., cycle• Stomach aches• Irritability• Rebound; wear off of meds• Less talkative, stares, ‗zombie‘• Tics• Skin picking 31
    32. 32. Diagnosis and MonitoringThe SNAP-IV Short Rating ScaleFor each item, check the column that best describes this child: Not At Just A Quite Very All Little A Bit Much1. Often fails to give close attention to details or makes careless mistakes in schoolwork or tasks ____ ____ ____ ____2. Often has difficulty sustaining attention in tasks or play activities ____ ____ ____ ____3. Often does not seem to listen when spoken to directly ____ ____ ____ ____4. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties ____ ____ ____ ____5. Often has difficulty organizing tasks and activities ____ ____ ____ ____6. Often avoids, dislikes, or reluctantly engages in tasks requiring sustained mental effort ____ ____ ____ ____7. Often loses things necessary for activities (e.g. toys, school assignments, pencils, or books) ____ ____ ____ ____8. Often is distracted by extraneous stimuli ____ ____ ____ ____9. Often is forgetful in daily activities 32
    33. 33. Diagnosis and MonitoringFor each item, check the column that best describes this child: Not At Just A Quite Very All Little A Bit Much10. Often fidgets with hands or feet or squirms in seat ____ ____ ____ ____11. Often leaves seat in classroom or in other situations in which remaining seated is expected ____ ____ ____ ____12. Often runs about or climbs excessively in situations in which it is inappropriate ____ ____ ____ ____13. Often has difficulty playing or engaging in leisure activities quietly ____ ____ ____ ____14. Often is ―on the go‖ or often acts as if ―driven by a motor‖ ____ ____ ____ ____15. Often talks excessively ____ ____ ____ ____16. Often blurts out answers before questions have been completed ____ ____ ____ ____17. Often has difficulty awaiting turn ____ ____ ____ ____18. Often interrupts or intrudes on other (e.g. butts into conversations/ games) ____ ____ ____ ____ 33
    34. 34. ScoringThe 4-point response is scored 0 – 3 (Not at All= 0, Just A Little = 1, Quite A Bit = 2, and Very Much = 3). Subscale scores on the SNAP-IV are calculated by summing the scores on the items in the specific subset (eg., Inattention) and dividing by the number of items in the subset (eg., 9). The score for any subset is expressed as the Average Rating-Per-Item.Rating Scales II: SNAP scoring Tentative 5% cutoffs Teachers and ParentsADHD-Inattentive (1-9) Mean Total T 2.56 23 P 1.78 16ADHD-Hyperactive/Impulsive (10-18) T 1.78 16 P 1.44 13 34
    35. 35. School Goal Card – Daily Report 35
    36. 36. Managing Medication Outcomes Therapeutic Response Good Poor• Treat the side effects or • Reconsider diagnosis or switch to reassure & observe if side another first line agent effects persist • If diagnosis is correct, switch to a• Slightly lower the dose second line agent• Slightly lower the dose & High supplement with short-acting agent Adverse• Switch to another first line Effects agent• Continue therapy • Reconsider diagnosis • If diagnosis is correct, raise the dose or switch to another agent Low • Validate patient adherenceCanadian Attention Deficit Hyperactivity Disorder Resource Alliance (CADDRA): Canadian ADHD Practice Guidelines, First Edition. Toronto, ON; CADDRA 2006. 36
    37. 37. ResourcesSupport GroupsLook for support groups in your area on the CADDAC website (www.caddac.ca)under Resources.WebsitesCanadian ADHD Resource Alliance (CADDRA) – www.caddra.caCentre for ADD/ADHD Advocacy, Canada (CADDAC) – www.caddac.caAttention Deficit Disorder Association (ADDA) - www.add.orgAnswers to your questions about ADHD (Patricia O. Quinn, MD and KathleenNadeau, PhD) - www.ADDvance.comOnline catalogue of ADHD resources – www.addwarehouse.comQuebec-based Dr Annick Vincents ADHD website - www.attentiondeficit-info.comChildren and Adults with Attention Deficit Hyperactivity Disorder – www.chadd.orgConnecting doctors, parents and teachers – www.myadhd.comOnline planner - www.skoach.comTotally ADD – www.totallyadd.com 37
    38. 38. GOALS• Effectiveness• Duration• Minimal Adverse Effects• Management of Adverse Effects• Regular monitoring• Individualized schedule• Happy well functioning child/ adolescent• The ‗Science of effectiveness‘ for teens• Personal responsibility for one‘s own ADHD 38
    39. 39. ADHD Assessment Instruments/Tools• The following websites contain various types of ADHD testing tools:  www.neurotransmitter.net/adhdscales.html  www.massgeneral.org/schoolpsychiatry/screenin gtools_table.asp  SNAP-IV: www.adhdcanada.com/pdfs/SNAP- IVTeacherParetnRatingScale.pdf  Weiss Functional Impairment Scale: http://www.caddra.ca/english/pdfs/Child_7.pdf 39
    40. 40. QUESTIONS? 40
    41. 41. True or False?1. The best way to arrive at the correct dose of stimulant medication is by adjusting it to the weight of the child.2. Structured classrooms are useful locations for observations about ADHD features and responses to medication.3. Three times daily medication administration is usually best because fine adjustments can be made for each dose. 41
    42. 42. True or False?1. The best way to arrive at the correct dose of stimulant medication is by adjusting it to the weight of the child. FALSEClinical response of each individual child is the best indicator for adjusting medication.2. Well structured classrooms are useful locations for observations about ADHD features and responses to medication. TRUESettings with looser structure allow enough variation in activities that many features of ADHD may be far less noticeable.3. Three times daily medication administration is usually best because fine adjustments can be made for each dose. FALSESingle long acting doses tend to work more smoothly for the child through out the full day and have reduced potential for adverse effects. 42
    43. 43. Oppositional Defiant Disorder• Review the DSM IV TR• Primarily an environmentally determined disorder• Major predisposing factor—ADHD• Can be confused with normal developmental stage of development of autonomy—ages 2-3 43
    44. 44. The Non Compliance Cycle Parent commands Other Parent interactions Repeats Compliance command Loop repeats 3 to 7 times Compliance Parent threatens Loop repeats 3 to 7 times Compliance Parent Acquiescence ? AggressionPresentation by Barkley R. Original research, by Patterson G (?) 44
    45. 45. Three Pathways to Boys’ Problem Behaviour and Delinquency.AGE OF % BOYSONSET Few Late VIOLENCE MOD. To (rape, attack SERIOUS Strong arm) DELINQUENCY (fraud, burglary, Serious theft) PHYSICAL FIGHTING PROPERTY DAMAGE (physical fighting, (vandalism, fire setting) Gang fighting) AUTHORITY AVOIDANCE MINOR AGGRESSION (truancy, MINOR COVERT BEHAVIOR (bullying, annoying others) Running away, (shoplifting, frequent lying) Staying out late) OVERT PATHWAY COVERT PATHWAY) DEFIANCE/ DISOBEDIENCE Many Early STUBBORN BEHAVIOUR AUTHORITY CONFLICT PATHWAY (before age 12) Loeber R &Hay. Three developmental pathways to serious disruptive behaviours. 45
    46. 46. The Benefits of Treatment? One Study • Retrospective study of 25 adolescents age 15 at a Toronto residential setting: • Start of problems:  Age 4.7 years  First intervention age 6.48 years  Average number of CD symptoms: 5 • Age 16  15.6 Agencies  Average 8 months / agency  18.9 interventions  Average 7 months / intervention  Number of schools – 6.88  Average number of CD symptoms: 10.16Shamsie J. Conference on Conduct Disorder, Vancouver BC 1990. Later literatrue noted in following article.Shamsie J, Hamilton H, Sykes C. Can J Psychiatry 1996; 41:211-216. The Characteristics and Intervention Histories of Incarcerated and Conduct- 46Disordered Youth
    47. 47. ManagingDisruptive Behavioral Disorders 1. Program Infrastucture Cognitive Behavioral Approach 2. Assess and Manage Token Economy Therapeutic Classroom 3. Skill Building Relaxation Psycho-educational Anger Management 4. Classical Therapy (Blind Trials) Social Skills Medication Anxiety Management Individual Activity Based Unstructured Time 5. School Preparation ADL/ Recreation Occupational/ Family Behavioral Management 6. Child Computerized (CPT, Dominic) Management Training Group Medication Observation Parents – Mandatory Report Cards 7. In the Cooperative Activity Teachers . Community Child- Individual SchoolVisits Family Anxiety takers Home - Social 8. Case Conferencing Work Associated Care School Visits Parenting Schools Community Parents & Teachers– Individual Parent Community Child / 1 way mirror Observe Agencies (Health, FCS, Others) 47
    48. 48. Adapted from: The Discipline Pyramid. From McMahon, Slough, and Conduct Problems Prevention 48Research Group (1996). Copyright 1996 by Sage Publications, Inc.

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