Advances in the pharmacotherapy of attention deficit hyperactivity disorder


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stimulant and non stimulant drug therapy and behavioral therapy in attention deficit hyperactivity disorder ,

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  • To identify and compare the benefits of the different treatment approaches in ADHD, the National Institute of Mental Health (NIMH) undertook a large groundbreaking study called The Multimodal Treatment Study of ADHD (MTA Study). The study compared four treatment regimens:  Medication alone (monthly visits)Intensive behavioural therapyCombined treatment (medication and behavioural therapy together)Community care
  • The study compared four treatment regimens:  Medication alone (monthly visits)Intensive behavioural therapyCombined treatment (medication and behavioural therapy together)Community care
  • Medication alone and combined treatment did not differ significantly on any direct comparisons, but in several domains (eg, academics, social skills, parent-child relations, oppositional behaviour, anxiety/depression) combined treatment proved superior to intensive behavioural therapy and/or community care, while medication alone did not.
  • In reality, parents are not likely to receive training provided in the MTA Study, nor is it realistic to expect them to maintain the level of effort necessary to diligently enforce behavioural treatment strategies
  • Medication alone and combined treatment did not differ significantly on any direct comparisons, but in several domains (eg, academics, social skills, parent-child relations, oppositional behaviour, anxiety/depression) combined treatment proved superior to intensive behavioural therapy and/or community care, while medication alone did not.
  • Extented release of methylphenidate New delivery system for sustaining blood level of the drug over longer period as to reduce doses per day
  • Pulse- delivery system formed Immediate release pellet (50%)+50 % DELAYED – RELEASE PELLET = sli381 capsule
  • Abbreviation:ADHD: attention-deficit hyperactivity disorder, DSM-IV: Diagnostic and Statistical Manual of Mental Disorders, 4th edition, ATX: atomoxetineKey Points:Introduction:Here we see the results of an analysis of 6 major studies of ATX efficacy in children and adolescents (6 to 18 years old) who met the DSM-IV criteria for ADHD.Methods:The study design, with the exception of fixed-dose administration in 1 study, was similar across all 6 randomized, double-blind, placebo-controlled trials.Baseline severity score of at least 1.5 standard deviations (SD) above age and sex norms on the Attention-Deficit/Hyperactivity Disorder-IV-Parent Version: Investigator-Administered and Scored (ADHD RS) or 1.5 SD on the Conners’ Parent Rating Scale-Revised: Short Form (CPRS) and 1.0 SD on the ADHD RS Teacher Version for 1 study (study V)In 3 of these trials, ATX was administered twice daily in the morning and late afternoon/early evening. Two were identical dose-titration studies (Studies I and II) and the third (Study III) was a dose-response study. In the other 3 trials, ATX was administered once daily in the morning. Doses ranged from 0.5 to 1.8 mg/kg/day (2 studies allowed up to 2.0 mg/kg/day, 1 study allowed up to 1.5 mg/kg/day)Study designs, except for dose administration, were otherwise similar across trials.After a diagnosis assessment period (about 2 weeks), patients were randomly assigned into a 6- to 9-week, double-blind, placebo-controlled acute treatment period and received either atomoxetine or placebo. Results:ATX demonstrated a statistically significantly (p.05) greater mean reduction in ADHD symptoms compared with placebo on the primary efficacy measure (ADHD-RS, investigator-rated and scored based on parent [5 studies] or teacher [1 study] reports) in all of the acute studies.Efficacy was also demonstrated in both hyperactive/impulsive and inattentive symptom domains, as well as in younger children and adolescents, in patients with ADHD alone or with ADHD and a comorbidity, and in patients with or without prior stimulant use.Conclusion:Whether the data were analyzed using the LOCF approach or repeated measures mixed models, similar results were obtained, demonstrating a marked and statistically significant effect in favor of atomoxetine. References:Studies I, II (B4Z-MC-HFBD, -HFBK): Spencer T, Heiligenstein JH, Biederman J, Faries DE, Kratochvil CJ, Conners CK, Potter WZ. Results from 2 proof-of-concept placebo-controlledstudies of atomoxetine in childrenwith attention-deficit/hyperactivitydisorder. J Clin Psychiatry 2002;63(12):1140-7. Data extracted from Table 2, p. 1145.Study III (B4Z-MC-LYAC): Michelson D, Faries D, Wernicke J, Kelsey D, Kendrick K, Sallee FR, Spencer T, and the Atomoxetine ADHD Study Group. Atomoxetine in the treatment of children and adolescents with attention-deficit/hyperactivitydisorder: a randomized, placebo-controlled, dose-responsestudy. Pediatrics 2001;108(5):e83. Data extracted from Table 3, p. e5.Study IV (B4Z-MC-LYAT): Michelson D, Allen AJ, Busner J, Casat C, Dunn D, Kratochvil C, Newcorn J, Sallee FR, Sangal RB, Saylor K, West S, Kelsey D, Wernicke J, Trapp NJ, Harder D. Once-daily atomoxetine treatment for children and adolescents with attention-deficit/hyperactivity disorder: a randomized, placebo-controlled study. Am J Psychiatry 2002;159(11):1896-901. Data extracted from Table 2, p. 1898.Study V (B4Z-MC-LYAW): Weiss M, Tannock R, Kratochvil C, Dunn D, Velez-Borras J, Thomason C, Tamura R, Kelsey D, Stevens L, Allen AJ. A randomized, placebo-controlled study of once-daily atomoxetine in the school setting in children with ADHD. J Am Acad Child Adolesc Psychiatry. 2005;44(7):647-55. Data extracted from Table 2, p. 651.Study VI (B4Z-US-HFBG): Kelsey D, Sumner C, Casat C, Coury DL, Quintana H, Saylor KE, Sutton VK, Gonzales J, Malcolm SK, Schuh KJ, Allen AJ. Once-daily atomoxetine treatment for children with attention-deficit/hyperactivity disorder, including an assessment of evening and morning behavior: a double-blind, placebo-controlled trial. Pediatrics 2004;114(1):e1-8. Data extracted from Table 2, p. e5.Alt. Source: Simpson et al. Poster presented at AEP 2004: “Rvw.P.Simpson.EfficacyUpdate_w_SDbars.AEP0404.ppt” Atom00046805
  • Advances in the pharmacotherapy of attention deficit hyperactivity disorder

    1. 1. Prof. Heba Essawy Professor of Psychiatry Ain Shams University RECENT ADVANCES IN THE PHARMACOTHERAPY OF ADHD
    2. 2. Roadmap  MTS Study  Psycho stimulants therapy in ADHD  Non – stimulants in treatment of ADHD  Impact of ADHD treatment and comorbidity  Alterative treatment approaches in treating ADHD
    3. 3. ADHD: Components of Treatment  Medical Interventions  Behavioral Interventions  Psychosocial Interventions  Education
    4. 4. ADHD: Treatment Planning Goals  Reduce major symptoms of ADHD  Improve functioning in areas of impairment Plan  Address individual target symptoms  Reassess and modify as necessary Conners CK;*Jett JL. Attention Deficit Hyperactivity Disorder in Adults and children; The Latest Assessment and Treatment Strategies; 1999. Dulcan M. J Am Acad Child Adolesc Psychiatry. 1997;36 (10 suppl):85S-121S.
    5. 5. ADHD: MTA Study NIMH and US Department of Education  14-month, multicentre, randomized, controlled trial  579 children, ages 7-9 years, ADHD combined type  Medication management utilized dosing strategies for all-day coverage MTA Cooperative Group. Arch Gen Psychiatry. 1999;56(12):1073-1086.
    6. 6. Rationale for Multimodal Interventions  Medical and psychosocial interventions have dose effects; outcomes differ among children  Multimodal therapy address comorbid conditions or target symptoms not sufficiently improved by medication or behavioural treatment alone  Potential to improve outcomes in patients Richters JE et al. J Am Acad child Adolesc Psychiatry. 1995;34(8):987-1000 Pelham WE Jr et al. J Clin Child Psychol. 1998;27(2):190-205.
    7. 7. ADHD: MTA Treatment Arms 1-Medication management only  MPH tid, adjusted for best dose, other drugs if necessary; algorithmic dose adjustments; 2- Intensive behavioural treatment only  Parent training; structured teacher consultation; 8-week, full-time, summer treatment program; 12 weeks of half-time, classroom, behavioural specialist; case management by therapist/consultant 3-Medication management + behavioural treatment (combined) 4- Community-based care  After assessment by investigators, parents could seek community care (roughly 2/3 received medication MTA Cooperative Group. Arch Gen Psychiatry. 1999;56(12):1073-1086.
    8. 8. ADHD: MTA Results All treatments led to improvement in core ADHD symptoms Medication management alone Medication management behavioural treatment Nearly equal effectiveness and superior to both: Behavioural treatment alone Community-based treatment MTA Cooperative Group. Arch Gen Psychiatry. 1999;56(12):1073-1086.
    9. 9. Intensive Behavioural Treatment in the MTA Study  The intensive behavioural modification in the MTA Study is unrealistic in day-to-day life:  Parents received extensive training .  Children participate in an 8-week, 40-hour-perweek treatment program and received one-on- one help with classroom behaviour from an aide.  Parents, teachers, and therapists were required to maintain the highest possible degree of communication.
    10. 10. MTA Study Conclusions  Medication alone and combination regimens were the most effective at reducing core ADHD symptoms.  Behavioural therapy alone was not effective at reducing core ADHD symptoms, but did help to promote positive interactions with others and alleviate non-ADHD symptoms such as aggressive behaviour, anxiety, and depression Conners CK;*Jett JL. Attention Deficit Hyperactivity Disorder in Adults and children; The Latest Assessment and Treatment Strategies; 1999
    11. 11. ADHD Treatment : Stimulants  Stimulant medications are the  Most studied  Most commonly used  Most effective  First-line agents for treatment Dulcan M. J Am Acad Child Adolesc Psychiatry; 1997; 36 (10 suppl.):85S-121S Spencer T, et al. J Am Acad Child Adolesc Psychiatry. 1996;35(4):409-432.
    12. 12.  ADHD Treatment : Stimulants (cont.) Stimulant drugs effective in all age groups  Vast majority of controlled studies in school-age boys (6-12 years old) School-age Adolescents Adults Preschool Studies of stimulants for ADHD by Age Group Spencer T et al. J Am Acad Child Adolesc Psychiatry. 1996; 35(4):409-432
    13. 13. ADHD: Stimulants Found to Improve Core symptoms And Inattention Executive function Impulsivity Impulsive aggression Hyperactivity Social interactions Academic productivity and accuracy Swanson JM, et al. Except Child. 1993;60:165-162.
    14. 14. ADHD: Stimulants (cont.)  Methylphenidate (Ritalin®; Methylin®; Metadate®; Concerta®; Daytrana (patch).  Amphetamine mixed salts (AdderaI|®) Contain d- and l amphetamine sulfate.  Dextroamphetamine(Dexedrine®, DextroStat®)  Pemoline(Cylerl®) ( liver toxicity )
    15. 15. ADHD: Response to Stimulants Meta-Analysis of Within-Subject Comparative Trails Evaluating Response to Stimulant Medications 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 41% 28% 16% AMP MPH Equal response to Either Stimulant AMP: Amphetamine (AdderaI|®, Dexedrine®; DextroStat®) MPH: Methylphenidate (Ritalin®; Others) Arnold LE. J Am Disord. 2000; 3(4):200
    16. 16. ADHD: Stimulant Dosing  Medication should be given 7 days/week during initiation of therapy and through titration to optimal effect  Coverage throughout the day is a goal  This strategy allows  Parents of children receiving medication to see medication effects and benefits in off-school hours  Better assessment of efficacy and side effects
    17. 17. ADHD: Pediatric Stimulant Dosing Medication Starting Dose Titration Rate 5 mg qd or 5mg bid 5-10 mg every 3-5 days Usual Dosing Interval (Hours) 3 to 4 usually bidtid Dexedrir® DextroStat® (dextroamphetamine) (short-acting) 2.5-5 mg qd 2.5-5 mg every 3-5 days 4 to 6 usually bidtid Adderall® (mixed amphetamine salts) 2.5-5 mg qd 2.5-5 mg every 3-5 days 4 to 6 usually qdbid 37.5 mg q AM 18.75 mg/week qd Ritalin® (methylphenidate) (shortacting) Cylert® (pemoline) Findling RL., Dogin JW. J Clin Psychiatry. 1998;59(suppl 7):42-49. Ella J, et al. N Engl J Med. 1999;340(10):780-788. Cyr M, Brown CS. Drugs. 1998;56(2):2 5-223.
    18. 18. The Impetus for Once-Daily Dosage Options  Need for medication coverage tor  After-school extracurricular activities  Social interactions  Homework hours  Problems with in-school dosing - Privacy issues - Ridicule by peers; decreased self-esteem
    19. 19. ADHD: New Delivery Systems Newer once-daily dosage forms  Concerta® (OROS® methylphenidate) FDA approved, August 2000  Metadate CD@ (extended-release methylphenidate) FDA approved, April 2001  Adderall XRTM (extended-release amphetamine salts)  Daytrana TM (transdermal methylphenidate)
    20. 20. OROS® Methylphenidate Analogue Classroom Study  Single-site, double-blind, crossover: placebo, MPH tid, and OROS MPH  All participants known MPH responders  OROS MPH and IR MPH doses based on total daily MPH dose for each individual  5 mg MPH tid → 18 mg OROS qd  10 mg MPH tid → 36 mg OROS qd  15 mg MPH tid -—> 54 mg OROS qd  68 subjects, ages 6-12 years,
    21. 21. OROS® Methylphenidate: SKAMP Attention Ratings Pellham WE Jr. Presented at: APA 2000 Annual Meeting; May 13-18, 2000; Chicago, IL
    22. 22. OROS® Methylphenidate: Academic Productivity Pellham . Presented at the AM Psychiatric Assoc. Annual Meeting; May 17, 2000
    23. 23. Extended-Release Methylphenidate Capsules (Metadate CD®)  MPH 20 mg capsules use 2 beads  IR beads comprise 30% of dose (6 mg)  ER beads comprise 70% of dose (14 mg) for continuous release of drug  Approximately 8-hour duration of action  1 multisite, placebo-controlled, doubleblind, clinical trial  Doses individually titrated  CGIS-T morning and afternoon ratings showed significant improvement compared to placebo (P<.001)
    24. 24. SLI381: Extended-Release Amphetamine Salts (Adderall XRTM) Pulse-Delivery System Drug Layer Overcoating Drug Layer Overcoating Release-Delaying Polymer Bead Overcoating 50% 50% SLI381 Capsule
    25. 25. SLI381 (Adderall XRTM): Academic Productivity Number of Math Problems Completed Correctly McCracken JT, et al. Presented at: AACAP Annual Meeting; Oct 24-29, 2000; New York.
    26. 26. Stimulant Adverse Effects (AE)  Adverse effects are similar for all stimulants  Decreased appetite  Insomnia  Headache  Stomachache  Irritability/rebound phenomena NB: Rates of these adverse events may be high prior to any medical intervention so baseline levels should always be obtained
    27. 27. ADHD: AE Management Strategies  Decreased appetite  Monitor weight  Administer with or after meals  Give high-calorie snacks  Initiate bedtime snacking  Consider drug holidays
    28. 28. ADHD: AE Management Strategies (cont.)  Insomnia - May be related to ADHD itself, a comorbid disorder, or treatment  Sleep hygiene/relaxation training  Avoid evening dosing of stimulant  Administer dose earlier in the day  Try longer-acting preparation
    29. 29. ADHD: AE Management Strategies (cont.)  Headache/stomachache  Decrease dose  Switch to another stimulant  Switch to second-line agent
    30. 30. ADHD: AE Management Strategies (cont.)  Irritability/moodiness; rebound effects  Assess time occurring  Shortly after dosing: may need to decrease dose  Between doses (wearing off of medication): may be rebound phenomena  Adjust dosage  Try longer-acting preparation  Assess for other disorders
    31. 31. ADHD: Other Issues with Stimulants Growth suppression  Weight: some studies show modest mean weight deficits in ADHD children; other studies show none  Research suggests that stimulant treatment may result in small effects in growth in weight in some children  Limited clinical concern  Offset by adjustments in medication administration and food supplementation Spencer TJ, et al. J Am Acad Child Adolesc Psychiatry. 1996;35(11):1460-1469.
    32. 32. ADHD: Other Issues with Stimulants (cont.) Growth suppression  Height: some studies have reported deficits in growth in height in children (height deficits of 13 cm) whereas others have not  Deficits found in prepubertal children but not in adolescents  Reports of increased growth during drug holidays may reflect spontaneous normalisation - of height gain  Catch-up gains in height even with continued stimulant treatment Spencer TJ, et al. J Am Acad Child Adolesc Psychiatry. 1996;35(11):1460-1469.
    33. 33. ADHD: Other Issues with Stimulants (cont.) Induction or exacerbation of tics  Tics are usually transient; rarely patients develop a chronic tic disorder  When tics occur or increase  Decrease dose  Switch to another stimulant  Adjunct agent to treat tics  Try non stimulant medication
    34. 34. ADHD: Other Issues with Stimulants (cont.)  Pharmacotherapy and substance abuse  Fear: stimulant therapy may lead to substance abuse  Fact: untreated ADHD is a significant risk factor for substance abuse in adolescence  Pharmacotherapy for ADHD may have protective effects
    35. 35. ADHD: Pharmacotherapy and Substance Abuse 35% Overall Rate of PSUD P<.001 30% % of Group 25% 20% 15% 33% 10% 13% 5% 10% 0% unmedicated ADHD (n=19) Biederman J, et al. Pediatrics. 1999; 104(2):20. Medicated ADHD (n=56) Control (n=137)
    36. 36. Nonstimulant Medications in ADHD: Sales TCAs (n=33) MAOIs (n=4) SSRIS (n=1) Venlafaxine (n=5) Alpha-adrenergic agents (n=7) Neuroleptics (n=12)
    37. 37. ADHD: Tricyclic Antidepressants Advantages Disadvantages Established efficacy in ADHD Long duration of action Efficacy <stimulants Potential benefits on mood and anxiety Need for cardiac monitoring May be useful in patients with tic disorders Positive effects on sleep Biederman J. J Clin Psychiatry. 1998;59(suppl 7):4-16. Serious potential cardiac effects in children
    38. 38. ADHD: Bupropion (Wellbutrin®) Advantages Disadvantages Efficacy in ADHD Few studies in ADHD Adequate duration of action (bid dosing) Limited effect size May decrease hyperactivity and aggression May decrease threshold May improve cognitive performance May exacerbate tics Smoking cessation Conners CK, at al. J Am Acad Child Adolesc Psychiatry. 1996;35(10)=1314-1321. Biederman J. J Clin Psychiatry. 1998;59(suppl 7) :4-16. seizure
    39. 39. ADHD: Clonidine (Catapres®) Advantages Disadvantages Activity in aggressivity and agitation Clinical effects may take several weeks Improves ability to fall asleep Does not affect inattention symptoms Sedation, disrupted REM sleep Risk of adverse cardiovascular effects, depression, and decreased glucose tolerance
    40. 40. ADHD: Guanfacine (Tenex®) Advantages Disadvantages Longer duration of action than clonidine Very limited efficacy and safety data Less sedation than clonidine Sedation
    41. 41. Pediatric Dosing Guidelines Medication Average Daily Dose TCA antidepressants Desipramine Imipramine Titrated up to 25-150 mg (1-5 mg/kg) Nortriptyline Titrated up to 10-75 mg (0.5-3 mglkg) Other antidepressants Bupropion 3.0-6.0 mg/kg* Venlafaxine 2.0-5.0 mg/kg* Alpha-adrenergic agents Clonidine 0.1-0.3 mg* Guanfacine 0.5-3.0 mg* *Given In divided doses. Wilens TE, et al. J Am Acad Child Adolesc Psychiatry. 1999;38(6):614-619. Spencer T, et al. 1998. Conner DF, et al. J Child Adolesc Psychopharmacol. 1998;8(l):27-38.
    42. 42. Atomoxetine Receptor Activity  Potent selective inhibitor of norepinephrine reuptake  Increase extracellular NE but produces an indirect increase in dopamine in prefrontal cortex
    43. 43. Strattera® (atomoxetine HCl) Mechanism of Action Tyrosine Tyrosine Dopamine Dopamine Norepinephrine (NE) NE Presynaptic Neuron NE NE NE NE NE Transporter Atomoxetine Synaptic Cleft NE NE Receptor NE Receptor Postsynaptic Neuron Simpson D, et al. Drugs. 2004;64(2):205-222. Lilly confidential. Do not copy. Copyright © 2013 Eli Lilly and Company. 43
    44. 44. A Fixed-Dose Study of Atomoxetine and Placebo in Children and Adolescents Atomoxetine 1.8 mg/kg/d Atomoxetine 1.2 mg/Kg/d n=84 Atomoxetine 0.5 mg/kg/d n=44 Placebo Washout and Evaluatio n n=85 - n=84 8-Week Acute Therapy Period Extension (ongoing)
    45. 45. ADHD RS Total Score Improvement Atomoxetine Efficacy in placebo- controlled pediatric studies aaaa * * *** *** *** *** * a *p<.05 ***p≤.001 aIn Study III, 1.2 mg/kg/day is fixed dose, while in all other studies this dose represents a titrated dose 1. Spencer et al. J Clin Psychiatry 2002;63(12):1140-47. 2. Michelson et al. Pediatrics 2001;108(5):e83. 3. Michelson et al. Am J Psychiatry 2002;159(11):1896-901. 4. 5. Weiss et al. J Am Acad Child Adolesc Psychiatry 2005;44(7):64755. Kelsey et al. Pediatrics 2004;114(1):e1-8.
    46. 46. Child Health Questionnaire *Pairwise test vs placebo R-05. **Pairwise test vs placebo P<001. Test for linear dose response P<.05.
    47. 47. Tolerability of Atomoxetine in Children (All Placebo-Controlled Studies) Atomoxetine (N=425) Placebo (N=292) P-value Appetite decreased 60(14.1%) 17(5.8%.) <.001 Dizziness 26(6.1%) 7(2.4%) .019 Dermatitis 19(4.5%) 5(1.7%) .056 Dyspepsia 19(4.5%) 4(1.4%) .029 Unexpected benefit 13(3.1%) 3(1.0%) .077 Constipation 10(2.4%) 3(1.0%) .259 Mood swings 10(2.4%) 2(0.7%) .136 Influenza 9(2.1%) 3(1.0%) .377 Events reported by at least 2% of atomoxetine patients and at least two times more common than placebo.
    48. 48. ADHD: Childhood Common Comorbid Diagnoses Biederman J, et al. J Am Acad Child Adolesc Psychiatry. 1996;35(3):343-351. Pllszka SR. J Clin Psychiatry. 1998;59(surppl 1,50-58. Biederman J, at al. J Am Acad Child Adolesc Psychiatry. 1999;38(8):966-975. Spencer T, et al. Pediatr Clin North Am. 1999;46(5):915-927.
    49. 49. TREATMENT IMPACT OF CD  Stimulant medication or ATX effective and decrease - Physical aggression -Verbal aggression -Negative social interactions - Covert antisocial behaviour  Antihypertensive , atypical AP for highly aggressive , explosive cases  Mood stabilizers are unhelpful  Behavioural management techniques are employed Spencer T, et al Pediatr Clin North Am. 1999;46(5):915-927.
    50. 50. Treatment Impact of anxiety     Prioritize treatment Reduced response to stimulants Stimulants make anxiety worse ? Stimulants make some cognitive abilities worse in combined cases  ATX and GUANFACINE xr do not worsen anxiety in comorbid cases  SSRI may be effective for anxiety disorders  consider buspirone, high-potency benzodiazepines for anxiety Spencer T, et al. Pediatr Clin North Am. 1999;46(5):915-927. Conners CK J Attn Disord. 2001;4(suppl 1):30.
    51. 51. Treatment Impact of anxiety  Probe more for physical or sexual abuse or bulling at school  More responsive to behavioral therapy ( MTA)  Better response to social skill training
    52. 52. Treatment impact of Depression  Highly prevelant from 20 to 45%  Severe explosive anger may be a sign of either childhood severe mood dysregulation (SMD) or Bipolar disorder
    53. 53. Treatment impact of Depression  Combination therapy often required  Stimulants effective in treating ADHD but not mood  SSRIs may be effective in treating depression but not ADHD  Noradrenergic agents ATX may treat both  Antihypertensive , Atyipical AP and Mood stabilizer are useful. Spencer T, et al. Pediatr Clin North Am. 1999;46(5):915-927.
    54. 54. ADHD: Comorbid Depression (cont.) ADHD treatment  Noradrenergic antidepressants  Stimulants Depression treatment  SSRIs  Bupropion  Venlafaxine
    55. 55. Treatment Impact Of Bipolar Disorder  Juvenile mania is highly comorbid and frequently mixed with depressive features, ADHD, anxiety, and ODD/CD  Prioritize treatment  First treat mania or psychosis  Mood stabilizers  Atypical neuroleptic  ADHD
    56. 56. Impact of Treatment of Tics/Tourette's Tics develop in 1-2% of ADHD receiving high dose of Amphetamine but not Methylphenidate  Stimulant medication is not contraindicated  If unable to tolerate stimulants consider alternative ADHD medication (Atx or TCA)  Adjunctive agents for tic control can be successfully combined with stimulants (alpha agonist, risperidone, pimozide)
    57. 57. Treatment Impact Of ASD  20- 25% of ADHD have ASD.  20- 5-% of ASD have ADHD.  ADHD medication can be used to treat ADHD symptoms effectively in context of ASD
    58. 58. Treatment Impact of ODD  Both stimulants and ATX reduce ODD with ADHD but not ODD alone.  Requires adjunctive parents training in behavior management .  Response is aged related , 60-75% successful for children  25-35% treatment response after 13 ys of age .
    59. 59. TREATMENT OF IMPACT OF learning Disorders  Hand writing problem (60%)  Comprehension defect  Comorbid reading , spelling and math disorder do not improve from stimulants  Reading ability improve on ATX
    60. 60. TREATMENT OF IMPACT OF learning Disorders  Comorbid hand writing and comprehension defect are likely to improve from stimulants if secondary to ADHD itself
    61. 61. ADHD: Alternative Therapies Effective in ADHD children :  Fish oil  Lithium  Zinc Arnold LE. J Affn Disord. 1999;3(l):30.
    62. 62. ADHD: Alternative Therapies Limited data EPA Ineffective or dangerous Megavitamin therapy Flax seed oil Megamineral therapy Ginko preparation Caffeine EEG biofeedback Primrose oil L- carnitine DHA Mg- VIT B6- VIT C Arnold LE. J Attn Disord. 1999;3(1):30.
    63. 63. Summary: Treatment of ADHD  In treatment planning targeting major areas of impairment and comorbidities .  Treatment may employ balance of behavioral and medical intervention  Stimulant medications are the gold standard for medical intervention if no comorbidity is associated  Apply Low- Slow- GO approach to titrating doses