Attention deficit hyperactivity disorder


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What is Attention-Deficit/Hyperactivity Disorder?
Inattentive, hyperactive & impulsive to excessive degree compared with their peers.

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Babatunde Idowu Ogundipe M.D. M.P.H.
Comprehensive Clinical Services P.C.
October 7 2011

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  • Academic-as children with ADHD mature academic failures demoralization & poor self-esteem. Other areas children: high rates injuries, cigarette smoking, & substance abuse. In subgroup there is risk delinquency. Symptoms adults mirror those in children & associated with significant educational, occupational, & interpersonal difficulties.Like other psych disorders no objective tests.Epidemiology:Clinically significant symptoms equally prevalent among men & women in adults vs children more prevalent in boys than girls.
  • No single etiology ADHD. Multifactorial hypothesis, as with all neuropsychiatric conditions complex combination environmental, genetic, & biological factors. Also prenatal & Perinatal risk factors with ADHD. Prenatal & Perinatal risk factor: Results from Logistic Regression Model of Odds ratio’s for Prenatal & perinatal risk factors show increased odds ADHD with cigarette exposure, alcohol exposure, low birth weight, & parental ADHD( 8 fold increase).Heritability: Studies of dizygotic & monozygotic twins that have grown up in same environment. Heritability=0 no genetic input, =1 characteristic/disorder completely determined by genetics. Mean heritability ADHD = 0.75  75% etiologic contribution genetic vs depression (0.39), GAD (0.32), breast cancer (0.27), asthma (0.39).Candidate Genes: Once genetic contribution ADHD was revealed researchers began trying to identify candidate genes. Gene association most widely confirmed = 7-repeat allele D4 dopamine receptor gene (DTD4*7) genetic polymorphisms in D4 receptor, a defective gene found in 30% general population & 50%-60% ADHD population. + distinct pattern neuropsychological deficits (difficulty with working memory & executive function) compared with healthy controls.Also found Susceptibility genes: dopamine receptor gene D2 + DAT gene. Other research D4 receptor shown that in addition to dopamine, both epinephrine & norepinephrine agonists at DRD4*7 thus medications affecting either of these catecholamine's could also affect this dopaminergic system.Model of Executive Dysfunctions: Located in prefrontal cortex, explains cognitive & behavioral deficits associated with ADHD (Barkley, ADHD & the Nature of Self Control) Attention, impulsivity, & hyperactivity. 5 major executive functions enable individuals to recognize & control their actions to achieve a goal: (1) Response inhibition-delays & interrupts responses & controls interference to allow individuals to control verbal & motor impulses. (2) Nonverbal working memory-enables person to have sense of the past & future & a cognitive awareness of self (3) Verbal working memory- gives people ability to internalize receptive & expressive language for self questioning, self-description, & establishing rules for behavior. Together nonverbal + verbal working memories provide ability for reading comprehension & moral conduct. (4) Self-regulation of emotion & motivation. By internalizing visual & verbal stimuli, 2 working memories lead to development of the self-regulation of emotion & motivation that provides individuals the ability to control their emotions & the motivation & persistence necessary to meet their goals. (5) Reconstitution-form of play allowing individuals to analyze the experiences in their working memories to synthesize new responses, which they accept or reject based on the likelihood that the response can help them to achieve their goal. Of 5 executive functions response inhibition most obviously deficient in individuals with ADHD impairments observed in psychological & social abilities associated with other 4 executive functions.
  • Functional & structural magnetic resonance imaging has documented differences brains individuals with & without ADHD:Circuits controlling attention smaller & less active in individuals with ADHD than in controls. Circuits: parts prefrontal cortex controlling working memory, alerting, & response inhibition. These areas rich in catecholamine receptors- shows norepinephrine & dopamine involvement in ADHD.
  • ADHD with distinct pattern of challenges at each stage of development.Elementary School: Also activities of daily living i.e. grooming + hygiene may be struggle. Often have associated problems i.e. messy handwriting, difficulty with sleep, oppositional behavior, increased risk of accidents & enuresis.Longitudinal studies have shown 80% children with ADHD still exhibit symptoms in adolescence, period of particular stress & impairment.Adults: higher risk than those w/o ADHD of dropping out of school, being fired from their jobs & having marital problems. Typically with fewer years of schooling, lower occupational achievement & poor social skills thus experience higher levels anxiety & depression than general population. Recent research shows increased risk poor medical health, serious motor vehicle crashes, cigarette smoking, & drug abuse.Research: adults with ADHD attracted to occupations that are exciting & busy with an element of risk (i.e. sales, stock-broking, entrepreneurial ventures).Other: frequent changes in employment, poor planning abilities (i.e. organizing finances, handling college coursework), messiness, dangerous driving, unstable relationships/social isolation, + engagement in leisure activities that are highly absorbing or stimulating (i.e. downhill skiing, high-contact sports, surfing the internet). Difficulty organizing their homes (i.e. cooking regular meals, cleaning) & managing their children (i.e. packing lunches, getting them to appointments on time).
  • Document current & past symptoms & establish that these impairment via obtaining developmental & psychiatric history + performing physical exam.One must assess current symptoms of ADHD (next 2 slides)+ those in childhood (i.e. before age 7). Obtaining childhood history of ADHD essential to assessment. Self report rating scales help assess presence of ADHD symptoms in childhood. Problem is patient may have poor insight /have difficulty remembering symptoms in childhood thus important to also gather info from school records, report cards for objective evidence childhood ADHD. i.e. look for comments in records about patients attention (i.e. “daydreams,” “can’t focus”), activity level (i.e. “always up from her desk,”, “can’t sit still”) & impulsive behavior (i.e., “interrupts students when they’re working, “ “needs to learn to wait his turn or raise hand before answering”). + other sources i.e. teachers/parents.Physical exam: Helps to r/o medical causes of the symptoms i.e. neurological problems & thyroid abnormalities. Is seeming inattention/impulsivity due to visual/auditory impairment?To screen for problems that are consequence of having ADHD i.e.smoking, illicit drug use, fractures, poor nutrition, poor sleep hygiene.To identify contraindications to treatment with stimulant medication i.e hypertension, glaucoma.To record patients baseline weight which may change with treatment.Electronic testing(i.e. continuous performance tests) & neuropsychological tests may contribute to clinicians overall impression but neither with good sensitivity/specificity on their own for diagnosis.
  • Current ADHD symptoms can be assessed using standardized rating scales. Here are 18 ADHD symptoms from DSM-IV each rated on its frequency in past 6 months with 4 point scale (0=never/not at all – 3=very often/very much).Patient will meet diagnostic criteria for ADHD-inattentive type if with significant difficulty ( score of 2 or 3) for > 6 of 9 items inattentive symptoms.Patient will meet diagnostic criteria for ADHD-combined type if with significant difficulty ( score of 2 or 3) for > 6 of 9 items hyperactive/impulsive symptoms.Rare for adults to meet criteria ADHD-hyperactive/impulsive type w/o meeting threshold for inattentive symptoms.
  • Adults with ADHD may id problems associated with ADHD (i.e. procrastination, lack of motivation, mood lability, low self-esteem) as primary concern rather than core symptoms.Assessing comorbid conditions & differential diagnoses is necessary as adults with ADHD with high rates mood, anxiety, learning & personality disorders, & substance use & abuse. Comorbid conditions may require treatment, may provide relative contraindication to use stimulants, or may alter expected outcome of treatment.ADHD distinct disorder & its impairments present in absence comorbid conditions.Differential diagnosis: Certain conditions may mimic (or more commonly coexist) with ADHD:Conduct disorder-differ from ADHD, exhibit persistent antisocial behavior (lying, cheating, stealing)Oppositional defiant disorder-easily annoyed, hostile, defiant, spiteful, and negative.Major depressive disorder-as with ADHD may show signs inattention + become easily upset (must have also had 2 weeks depressed mood or loss of interest/pleasure in most activities, + c/o easy fatigue, loss of energy, but not hyperactivity).Bipolar disorder-mild/fluctuant cases, especially in children difficult to distinguish from ADHD (if substantial Bipolar ssxs clear mood impairments: elation, grandiosity, severe irritability & anger, decreased need for sleep, hypersexuality, racing thoughts).Anxiety disorders- hyperactive behaviors i.e.fidgeting & inattentive behaviors behaviors accompanied by persistent fears & worries.Substance-related disordersLearning disabilities- like ADHD learning disorders may impair academic/occupational functioning & frequently comorbid with ADHD. However characterized by specific learning impairment as evidenced by significant discrepancy individuals performance on standardized test in reading, math, or written expression & their education & intelligence.Medical conditions, especially endocrine disorders i.e. hypothyroidism & hyperthyroidism sxs similar to ADHD (rare in children)Sleep disorders-r/o as cause attentional problems before diagnosis ADHD made.Medication/illegal substance/alcohol sxs inattention, hyperactivity & impulsivity?Mental retardation- impairment adaptive functioning more severe than social, academic, & occupational impairment associated with ADHD, occurring with impairment in general intellectual functioning (i.e. IQ < 75).Pervasive Developmental disorders (autism & asperger’s)- may exhibit hyperactivity or fidgeting + impaired social, academic, & occupational functioning. Also exhibit disinterest or inability to participate in social interaction or limited & stereotyped behavior, interests, & activities.
  • Are the woman's symptoms and history consistent with adult attention-deficit hyperactivity disorder (ADHD)? What steps should be taken to confirm or rule out a diagnosis of ADHD? If the woman does have the disorder, what can be done to manage her symptoms?
  • When assessing adults as with children beneficial to have > 1 informants complete standardized rating scales.i.e someone who knows patient well (spouse, close friend, parent, sibling) & someone who knew patient well enough as child to rate their childhood behavior (i.e. parent, aunt, uncle).Issue is question over reliability patient self-report.ADHD familial so important to screen for family psychiatric history of ADHD. Also inquire whether 1st degree relatives have had problems with tics, drug use & criminal behavior. Not uncommon in ADHD-helps identify risks for patient.
  • Psychological: scarcity controlled studies on efficacy psycho social treatments. Variety of psychological interventions used:Education on disorder, involvement in support groups, skills training (vocational, organizational, time management, financial), coaching. Support groups can provide support, social contacts, educate patient on ADHD & useful coping strategies & skills training (i.e. how to use day planner, developing routines for meal time, delegating challenging tasks).Medication: 9 double-blind placebo-controlled crossover studies using standardized methods diagnosis & outcome. Meta-analysis of findings showed weighted mean response rate of 57% to Methylphenidate, 58% to Dextroamphetamine, & 10% to placebo.Several studies suggest symptom reduction is dose dependent with higher response rates accompanying higher doses.Atomoxetine (strattera) first medication to receive approval by the US Food & Drug Administration for treatment of ADHD in adults.
  • Four classes psychotropic drugs have been proven useful in management ADHD symptoms: stimulants (most effective, with relatively benign side effects), noradrenergic reuptake inhibitors, tricyclic antidepressants, & antihypertensive agents. All more effective than placebo.Stimulants: most commonly prescribed are methylphenidate (MPH) (Ritalin, Concerta, Medadate CD, Focalin), d-amphetamine (AMP) (Dexedrine or Dextrostat), d- & 1-AMP combination (Adderall, Adderall XR). MPH slows down dopamine reuptake from extracellular space & amphetamines increase dopamine release. MPH & Amphetamines most commonly prescribed meds for ADHD. Concerta=miniature osmotic pump resembling capsule oozing liquid MPH while traversing gut x 10-12 hrs. Medadate CD (can also be sprinkled on food) & Ritalin LA are tiny MPH pellets & last about 8-12 hours.AMP/MPH sustained attention, impulse control, reduction of task-irrelevant activity, + diminishes noisy & disruptive behavior. Children become more compliant with parental/teacher instructions, & sustain compliance, & cooperate better with others. Also improvements seen with aggression, handwriting, academic productivity & accuracy, persistence of effort, working memory, peer relationships, emotional control, & participation in sports.Trial stimulant medication requires titrating doses while monitoring ADHD symptoms ( by means of serial administration of a rating scale) & side effects (hypertension, insomnia, headaches, weight loss). Monitoring requires that patient take medication daily x 1 week. Optimal dose = no further reduction in ADHD sxs occurs & side effects are manageable. Compliance better with long-acting stimulant.Noradrenergic reuptake inhibitors: Bupropion (Wellbutrin) & atomoxetine (strattera). Bupropion affects both NE & DA. Atomoxetine 1st nonstimulant medication to be developed specifically for treatment ADHD & to have been initially pilot tested in adults rather than children. Good alternative adults that cannot tolerate stimulants, do not respond to them, or require full day coverage. Potent & specific norepinephrine reuptake inhibitor.Atomoxetine- safe & efficacious for treatment ADHD children, adolescents, & adults & comparable in clinical response to MPH.When patient does not respond to or tolerate stimulant, treatment with an antidepressant may be considered:Double-blind placebo-controlled studies of the efficacy of bupropion, desipramine, & atomoxetine in management ADHD in adults shown these to be slightly less effective than stimulants but more effective than placebo.Antidepressant medication: TCA’s (imipramine, desipramine). Useful in short term treatment of children with ADHD only when stimulants or atomoxetine not effective (best to use atomoxetine first as alternative given more safety data)Treatment response TCA’s adults =children 50-66% with clinically significant response.Antihypertensive medication: Clonidine (catapres) & guanfacine (Tenex) alpha-2-adrenergic agonists. Research to date Clonidine less effective than stimulants in improving inattention & school productivity but equally efficacious in reducing hyperactivity & moodiness. Also useful vs sleep disturbance seen in some ADHD children. Side effects: drowsiness, weakness, dizziness, occasional sleep disturbance.In general:Side effects tend to decrease in severity & stablize within 1st 3 months treatment.Current practice guidelines: follow patients monthly until condition stable then every 3 months thereafter to monitor symptoms, adverse events, compliance, vital signs, dosage, & life stressors.Long acting stimulants include: 12 hour formulation of Methylphenidate (Concerta), 10 hour formulation Methylphenidate (Ritalin LA, Metadate CD), a 6 hour formulation dexmethylphenidate (Focalin), & 12 hour dextroamphetamine (Adderall XR)
  • Attention deficit hyperactivity disorder

    1. 1. Attention-Deficit/HyperactivityDisorderBabatunde Idowu Ogundipe M.D. M.P.H.Comprehensive Clinical Services P.C.October 7 2011
    2. 2. What is Attention-Deficit/Hyperactivity Disorder?• Inattentive, hyperactive & impulsive to excessive degree compared with their peers.• Prevalence as high as 3%-10% of children & 1%-6% adults in the U.S.• High prevalence, global impairment, & chronicity has lead CDC to identify it as serious public health problem since 1999.• Areas impairment children:• Academic dysfunction.• Social dysfunction & skills deficits.• Areas impairment adults:• Occupational & vocational dysfunction.• Social impairment.• High rates of motor vehicle accidents.
    3. 3.
    4. 4. Etiology Attention-Deficit/Hyperactivity Disorder• Validity ADHD been established by research on neurobiological features:• Functional MRI studies- activity in frontal striatal networks in ADHD vs activity in anterior cingulate gyrus those without ADHD.• Positron Emission tomography – decreased frontal cortical activity affected adults + indicated methylphenidate increases extracellular dopamine levels by blocking dopamine transporter (DAT), particularly in striatum. Adults with ADHD been found to have two- fold increase in DAT-binding potential.
    5. 5. Attention-Deficit/Hyperactivity Disorder Developmental Course• Preschool: Children have difficulty with quiet, focused activities. Trouble cooperating with other children, engage in less play than peers & have difficulty managing transitions. More noncompliant with adult requests + are less socially skilled than children of same age.• Elementary School: Continued conflict with peers. Trouble organizing school-related tasks (i.e. doing homework & keeping desk in order) + underachieve in school even when with intellectual potential to do well.• Adolescence: At school inattentive, hyperactive & impulsive behaviors  difficulties completing projects & homework thus do not achieve academic potential. At home have more conflict with parents than do those without ADHD. Tend to be immature, get into trouble when unsupervised, have poor social skills & engage in high-risk activities (i.e. reckless driving, cigarette smoking, unprotected sex, marijuana use).
    6. 6. Attention-Deficit/Hyperactivity Disorder DiagnosisSteps in the diagnosis of attention-deficithyperactivity disorder (ADHD) in adults1. Assess current ADHD symptoms (within the last 6 months) using rating scaleswith adult norms.2. Establish a childhood history of ADHD.3. Assess functional impairment at home, work and school and in relationships.4. Obtain developmental history, including during prenatal, childhood and schoolyears.5. Obtain psychiatric history: rule out other psychiatric disorders or establishcomorbid diagnoses (e.g., learning disabilities, mood and anxietydisorders, personality disorders and substance abuse, especially marijuanaabuse).6. Obtain family psychiatric history, especially concerning learningproblems, attention and behavior problems, ADHD and tics. Enquire about allfirst-degree relatives (parents, siblings and offspring).7. Perform physical examination: rule out medical causes of symptoms(e.g., serious head injury, seizures, heart problems, thyroid problems) orcontraindications to medical therapy (e.g., hypertension, glaucoma). Weiss, Margaret. Assessment and Management of Attention-Deficit Hyperactivity Disorder in Adults (2003). CMAJ, 168:6, 715-722.
    7. 7. Attention-Deficit/Hyperactivity Disorder Diagnosis: AssessmentAsk the patient to indicate how often, using a 4-point scale (0 = “never or not at all,”1 = “sometimes orsomewhat,” 2 = “often or pretty much” or 3 = “very often or very much”), he or she has experienced thefollowing symptoms of ADHD in the past 6 months and whether they have persisted for at least 6 months:(1) Inattention• Does not pay close attention to what he or she is doing and makes careless mistakes• Has trouble paying attention to tasks• Has trouble following verbal instructions• Starts things but does not finish them• Has trouble getting organized• Tries to avoid doing things that require a lot of concentration• Misplaces things• Is easily distracted by other things going on• Is forgetful(2) Hyperactivity–impulsivity• Fidgets with hands or feet• Has trouble sitting still• Feels restless and jittery• Has trouble doing things quietly• Is a person who is “on the go”• Talks too much• Acts before thinking things through• Gets frustrated when having to wait for things• Interrupts other people’s conversations Weiss, Margaret. Assessment and Management of Attention-Deficit Hyperactivity Disorder in Adults (2003). CMAJ, 168:6, 715-722.
    8. 8. Attention-Deficit/Hyperactivity Disorder Diagnosis: AssessmentDiagnosisAll of the following criteria must be met for a diagnosis of ADHD:A. Six or more of the symptoms of either (1) or (2) above are rated as “often orpretty much” or “very often or very much” and have persisted for at least 6months. (For adults over the age of 50 years, only 3 or more symptoms rated“often” or “very often” are required to meet diagnostic thresholds.)B. Some symptoms of inattention or hyperactivity–impulsivity that causedimpairment were present in childhood.C. Some impairment from the symptoms is present in 2 or more settings (e.g., atwork, at school, at home, during leisure activities, when driving a car).D. There must be clear evidence of clinically significant impairment insocial, academic or occupational functioning.E. The symptoms do not occur exclusively during the course of a pervasivedevelopmental disorder, schizophrenia or other psychotic disorder and are notbetter accounted for by another mental disorder (e.g., mood disorder, anxietydisorder, dissociative disorder or personality disorder).The symptoms and diagnostic criteria are modified from the DSM-IV. Weiss, Margaret. Assessment and Management of Attention-Deficit Hyperactivity Disorder in Adults (2003). CMAJ, 168:6, 715-722.
    9. 9. A single 36-year-old woman is referred for a psychiatric evaluation to exploreoccupational and personal problems in her life. She reports that she has “always” hadproblems concentrating on her work, felt restless and acted impulsively (e.g., madecomments to people that she later regretted). She describes herself as chronicallydisorganized. She currently works as a computer technician and says that her workevaluations have indicated that she has often been late for meetings, made carelesserrors and disrupted her coworkers with her constant chatter. As for personalrelationships, she reports having had few friends. She suspects that she “burnt out”her friends with her high energy level and admits that her mind wanders duringserious conversations, leaving her friends feeling that she is selfish or does not care.Beyond these difficulties, the woman is in good physical health, with no history ofserious childhood illnesses. When asked about her childhood, she admits that shefrequently got into trouble for “acting before thinking.” Her report cards indicatedthat she was working below potential and that she had “atrocious handwriting.” Shewas eventually placed in a special class because she talked constantly and “would notsit in her seat.” Weiss, Margaret. Assessment and Management of Attention-Deficit Hyperactivity Disorder in Adults (2003). CMAJ, 168:6, 715-722.
    10. 10. The patient reports that she has experienced 6 of the inattention symptoms and 7 of thehyperactivity–impulsivity symptoms of ADHD “often” or “very often” over the past 6 months.She reports having experienced all 18 symptoms in her childhood. Her roommate is asked torate her current behavior using the Adult Inventory–4; this collateral information indicates thatthe patients behaviors are consistent with ADHD. No collateral informant is available to assessthe patients behavior in childhood; however, teachers comments on her report cards clearlyindicate a long-standing history of attention problems and disruptive behavior in school. Thepatient had a prior history of depression, although she is not depressed at the time ofassessment. Her presenting problems associated with ADHD existed before and after the onsetof her depression. Given the results of the assessment, her physician diagnoses ADHD–combined type (symptoms of both inattention and hyperactivity–impulsivity) and chooses acombination of medication and support to manage her symptoms. A trial of methylphenidate(15 mg orally, every 4 hours, 4 times during waking hours) is effective in reducing the severityof her symptoms, with mild appetite suppression and irritability as each dose wanes. Thepatient is switched to dextroamphetamine (15 mg orally twice daily) to improve compliance. Atwork, the patient requests assignments that are interesting but challenging, instead of rotetasks that she finds boring and tedious. Socially, she monitors the physical distance betweenherself and others so that she can behave more appropriately. To improve her organizationalskills, she learns how to use an electronic planner. Two years after the diagnosis, the patient isproud that she is still employed with the same company and is better able to form and maintainfriendships. Weiss, Margaret. Assessment and Management of Attention-Deficit Hyperactivity Disorder in Adults (2003). CMAJ, 168:6, 715-722.
    11. 11. Assessment of patient’s developmental historyPrenatal• Did your mother use drugs, nicotine or alcohol when she was pregnant with you?• Do you know if there was difficulty during pregnancy or childbirth such as diabetes, eclampsia, cord around the neck, breech delivery or lack ofoxygen?Childhood• Were you described as a very active or impulsive child?• Did your parents complain that you were difficult?• Did you have any accidents requiring hospital treatment as a child?• Were you exposed to any physical, verbal or emotional abuse? Were you neglected?• Did you have any serious trauma, exposure to violence or losses as a child?• Did you have any medical illnesses as a child?• Did you ever lose consciousness?School• How did you do academically in elementary school? In high school?• Were you ever enrolled in college or university? Did you drop out? Why?• Did you ever fail a grade?• Did you ever have psychological testing or were told you had a learning disability?• Did you receive learning assistance or were you ever placed in a special class?• Were you ever suspended or expelled from school?• Did you have any special problems with reading? Arithmetic? Writing?• Did teachers complain that you were not achieving your potential or were not trying your best?• Was your performance at school variable or unpredictable?Family psychiatric historyHave your parents, siblings or children had any of the following problems?• ADHD• Depression• Anxiety (worrying, fears, extreme embarrassment in front of people, repetitive behaviors that do not make sense)• Psychosis (hearing voices, seeing things, or having fixed, wrong ideas)• Tics (involuntary and repetitive movements or sounds)• Substance abuse or alcoholism• Learning disability• Behavior problems or problems with the law• Suicide attempt or self-destructive behavior Weiss, Margaret. Assessment and Management of Attention-Deficit Hyperactivity Disorder in Adults (2003). CMAJ, 168:6, 715-722.
    12. 12. Attention-Deficit/Hyperactivity Disorder Management• Treatment c/o 3 parts:• (1)Education on ADHD + psychological support to the patient & family.• (2) Medication.• (3) Follow up and continued support.• Medication 1st line for ADHD & effective & safe in adults & children:• First Line:• Stimulants• Second Line:• Tricyclic Antidepressants• Bupropion• Atomoxetine
    13. 13. Medication Dose Durati Schedule Rate Adverse Events ADR management on (h) titrationFirst Line: Start at 5- 3.5 3-4 x/day 0.5- Decreased appetite, Discuss dietary needsMethylphenidate 10mg PO BID, 1.0mg/kg insomnia, Decrease late day dosing;switch to max 80mg/d daily long acting medication;discuss sleep hygiene. Headache (few wks only) If headache severe consider change of dose or switch to anotherDextroamphetam Start at 5mg 5 2-3x/day 0.5mg/kg stimulant/medine PO once daily or 5mg nervousness/dysphoria Consider use of antidepressant; r/o daily BID, qweek. comorbid disorder max 40mg/dSecond Line: Start at 24 Every 25-50mg Constipation High-fiber dietDesipramine or 50mg/d, max night every week Dry mouth Advise no drinks sweetened with sugarImipramine 200mg/d + get regular dental check ups.(response after 4weeks) Postural hypotension Advise to get up slowly Tachycardia /arrhythmia Lower dose Drowsiness(1st few days)Bupropion SR Start at 12 2x daily 50mg every Seizures Keep doses within recommended max,(response after 5 100mg in am, (8h apart) week ensure max 8h between doses; avoidweeks) max 15om use in patients at risk seizures i.e. BID eating disorder, alcohol abuse, h/o seizure Insomnia Take earlier in day/ single dose in am Headache Adjust doseAtomoxetine daily Decreased appetite/wgt loss (early only)
    14. 14. References• FIRST AID for the USMLE 3, Tao Le, Vikas Bhushan, Robert W. Grow, Veronique Tache.• Psychiatry History Taking. Third Edition. A Current Clinical Strategies medical book. Alex Kolevzon, Craig L.Katz.• Barkley, Russell. A. Adolescents with Attention- Deficit/Hyperactivity Disorder: An Overview of Empirically Based Treatments (2004). Journal of Psychiatric Practice, 10:1, 39-56.• Weiss, Margaret. Assessment and Management of Attention- Deficit Hyperactivity Disorder in Adults (2003). CMAJ, 168:6, 715- 722.• Spencer, Thomas al. Overview and Neurobiology of Attention- Deficit/Hyperactivity Disorder (2002). Journal of Clinical Psychiatry, 63, 3-9.• Brown, Ronald T. et al. Treatment of Attention- Deficit/Hyperactivity Disorder: Overview of the Evidence (2005). Pediatrics, 115, 749-757.