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Pharmacologic Treatments
of AD/HD
Paul P. Doghramji Jr.
March 30, 2009
Presentation Outline
Definition and Diagnosis
Neurobiology
Prevalence and co-morbidities
Pharmacologic treatments
Stimulants
Non-stimulants
Non-pharmacologic Treatments
CBT
IPT
Neurofeedback
Optimal treatment: Combination
Attention Deficit/Hyperactivity
Disorder
Neurobehavioral developmental disorder
Characterized by:
Inattention
Hyperactivity
Impulsivity
Very often co-morbid with:
Learning disabilities
Psychiatric disorders
AD/HD Diagnosis (DSM-IV*)
Persistent (>6 months) pattern of
developmentally inappropriate inattention and/or
hyperactivity-impulsivity
Symptom onset before age 7
Symptoms present in >2 settings (eg, home and
school)
Interference with social, academic, or
occupational functioning
Disorder not accounted for by another mental
disorder
*American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text
Revision. Washington, DC, American Psychiatric Association, 2000
Inattention Symptoms (DSM-IV)
1. Often does not give close attention to details or makes
careless mistakes in schoolwork, work, or other activities.
2. Often has trouble keeping attention on tasks or play
activities.
3. Often does not seem to listen when spoken to directly.
4. Often does not follow instructions and fails to finish
schoolwork, chores, or duties in the workplace (not due to
oppositional behavior or failure to understand instructions).
5. Often has trouble organizing activities.
6. 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).
7. Often loses things needed for tasks and activities (e.g. toys,
school assignments, pencils, books, or tools).
8. Is often easily distracted.
9. Is often forgetful in daily activities.
Hyperactivity/Inpulsivity (DSM-IV)
Hyperactivity
1. Often fidgets with hands or feet or squirms in seat.
2. Often gets up from seat when remaining in seat is expected.
3. Often runs about or climbs when and where it is not
appropriate (adolescents or adults may feel very restless).
4. Often has trouble playing or enjoying leisure activities quietly.
5. Is often "on the go" or often acts as if "driven by a motor".
6. Often talks excessively.
Impulsivity
1. Often blurts out answers before questions have been finished.
2. Often has trouble waiting one's turn.
3. Often interrupts or intrudes on others (e.g., butts into
conversations or games).
Neurobiology of ADHD
Specific etiology unknown but involves
combination of genetic and acquired
factors
Up to 90% heritability
Neuroimaging anomalies
(structural/metabolic) in frontal cortex
and basal ganglia ADHD
Prefrontal cortex dysfunction
fundamental to symptomatology
Biochemical abnormalities: possible
alterations in dopamine and/or
norepinephrine
Normal
Prevalence
Affects 6% to 10% of school-aged children1-3
– Diagnosed in boys 3 times more than in girls2,3
Accounts for 30% to 50% of mental health
referrals4
One of 10 most common pediatric concerns5
Resulted in over 10 million physician office visits in
2001
Up to 65% of children with ADHD continue to experience the
disorder into adulthood.
Co-morbidities
87% have at least 1 and 56% have at least 2
additional psychiatric disorders
Common co-morbidities include
Depression
Anxiety
Substance abuse disorder
Insomnia
Bipolar disorder
Oppositional Defiance Disorder (ODD)
ADHD: Drug Therapy
Stimulants Non-Stimulants
Methylphenidate Atomoxetine
D-amphetamine, Clonidine
mixed amphetamine
salts Antidepressants
Dextroamphetamine
Lisdexamphetamine
Modafinil
Dexmethylphenidate
ADHD: Drug Therapy
Traditional Stimulants Non-Stimulants
Advantages • Highly effective • Non-scheduled
• Rapid onset of effect • Compatibility with co-
• Long term experience morbidities
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Problems With
Neurofeedeback
Treatment lasts at least 40 sessions
Treatments are expensive
Treatment requires child motivation, boredom
renders slightly ineffective
Age is a major factor
Too young - child won’t do what is required
Adults and older - more difficult to make EEG
changes and receive good results
Treatment doesn’t work for everyone; greater
than 90% success rate
NIH Multimodal Treatment Study
of ADHD in Children (MTA Study)
Methods comparing 4 methods of intervention
medication management (MM)
intensive behavioral treatment
the 2 combined
treatment by community providers
Results
MM or combined treatment were significantly superior to community
and behavioral treatment after 14 months
Parent satisfaction was highest for behavioral interventions
Behavioral modification in combination with MM may reduce the need
for higher doses of medication
Behavior modification seen to be best for children with co-morbidities,
and/or whose families have limited financial resources
Conculsion
ADHD is a common psychopathology in
children and adults with much
impairment and disability
Two forms of treatment include
pharmacological and behavioral
The combination of management
methods seem to be most effective
References
1. Castellanos et al. Arch Gen Psychiatry. 1996;53:607-616.
2. Castellanos et al. Arch Gen Psychiatry. 2001;58:289-295.
3. Cook et al. Am J Hum Genet. 1995;56:993-998.
4. LaHoste et al. Mol Psychiatry. 1996;1:121-124.
5. . Egan et al. Proc Natl Acad Sci U S A. 2001;98:6917-6922.
6. . Fossella et al. BMC Neurosci. 2002;3:14.
7. MTA Cooperative Group. Arch Gen Psychiatry. 1999;56:1073-1086.
8. Donnelly et al. Differential Diagnosis and Treatment of Adult ADHD and Neighboring Disorders. 2006; 13:1-4
9. Arnsten AFT. Fundamentals of attention-deficit/hyperactivity disorder; circuits and pathways, J Clin Psychiatry
2006; 67 (suppl 8):7-12
10. Biederman J, Lopez FA, Boellner SW et al. A randomized, double-blind, placebo controlled, parallel-group study of
SLI381 (Adderall XR) in children with attention deficit/hyperactivity disorder. Pediatrics 2002; 110:258-66.
11. Grcevich SJ, Sea D, Mays D et al. Safety and efficacy of mixed amphetamine salts XR in adolescents with ADHD.
Presented at the 31st Annual Meeting of the American Academy of Child and Adolescent Psychiatry (Oct 19-
24,2004), Washington, DC, USA
12. J Am Acad Child Adolesc Psychiatry. 2002; 41:S26-49.15