4.1Pediatrics Autism and ADHD 2014A
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Transcript of 4.1Pediatrics Autism and ADHD 2014A
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AUTISM AND ADHD
July 13, 2012
Dr. Eusebio
OUTLINE
I. Autistic Spectrum Disorder
II. Autism
Prevalence
Etiology
Diagnosis
Early Signs
Comprehensive evaluation
DSM IV Criteria
Laboratory
Accompanying problems
Management
III. ADHD
Introduction
Prevalence
Causes
Signs and symptoms
Developmental Trend
Co-morbidities
Diagnosis
DSM IV
Treatment
o Standard treatment
o Medications
o Non traditional treatment
Burden of ADHD
AUTISTIC SPECTRUM DISORDER
THE EVOLVING NOMENCLATURE OF AUTISM
1943Kanners autism
1944Aspergers syndrome
1988 Autistic Disorder/Pervasive Developmental Disorder
(DSM-IIIDSM-III R)
1994Autistic Disorder/PDD (DSM IV; ICD 10)
1995Autistic Spectrum Disorders
He wandered about smiling, making stereotyped movements with
his fingers. He shook his head from side to side, whispering or
humming the same 3 note tune. He spun anything he could seize
upon to spin (Kanner 1943).
PDD (Pervasive Developmental Disorder) and ASD (Autistic Spectrum
Disorder) are one in the same. We use PDD is less stigmatizing.
Other subgroub Non-Autistic PDDs:
Aspergers Syndrome - is still an ASD but with normal
language development, however it is still peculiar
PDD NOS
Fragile X Syndrome
Retts syndrome
Chhildhood Disintegrative Disorder
A catch-all term when referring to the spectrum of autism
disorders
Under the pervasive developmental disorders (PDD) spectrum which
also includes Aspergers, childhood disintegrative, Retts and PDD no
otherwise specified (NOS) disorders
o
All share the inability to attain expected social and
communication, emotional, cognitive and adaptive abilities
Can be understood as disturbances of brain development with genetic
underpinnings.
AUTISM
A complex developmental disability that typically appears
during the first three years of life
The result of neurological disorder that affects the functioning
of the brain
TRIADS OF IMPAIRMENTS
o Impaired social relatedness
o Impaired communication and play
o Presence of stereotypic and/or ritualistic activities
A lifetime disability
Results from a brain dysfunction but the exact etiology is
unknown
Early and appropriate intervention have a positive impact on
overall outcome
THE CONCEPT OF DEVELOPMENTAL DISORDERS
Autism is a developmental disorder, a condition a child is
believed to be born with, or born with a potential fo
developing
This concept should be emphasized to parents. It has nothing to
do with pregnancy, poor child rearing, or anything in the
environment.
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PREVALENCE
The US Center for Disease Control has declared autism as the
fastest growing serious developmental disability
Autism rate doubles every 2 years:
o 1990: 1 out of 10,000
2007: 1 out of 150
A new CDC report:
o
One in every 110 American children
o One in every 70 boys
4:1 ratio of boys to girls
Represent a 57% increase from 2002 to 2006
An astonishing 600% rise in the past 20 years
Autism Epidemicor not?
The work epidemic must be used with caution. We must avoid unnecessary
panic and be mindful that labels can be misleading.
ETIOLOGY
Exact cause still is unknown
ASDs are biologically based neurodevelopmental disorders that
are highly heritable
GENETICS
Involve multiple genes; demonstrate great phenotypic variation
A rare mutation involving the deletion or duplication of 25
genes on chromosome 16 over 1% of autism cases in the US
(Autism Update, Harvard Magazine, May-June 2011)
Estimates of recurrence risks: 5-6% (range: 2-8%) when there is
an older sibling with an ASD and even higher when there are
already 2 children with ASDs in the family. (Dr. Eusebio said
that the risk is 6-10%)
AUTISM AND VACCINES
Researches on Vaccinations:
o The final report from IOM, Immunization Safety Review
Vaccines and Autism, released in May 2004, stated that
the committee did not find a link.
Until 1999, DPT, Hib, and Hep B contained thimerosal as a
preservative
Today, with the exception of some flu vaccines, none of the
vaccines to protect preschool aged children against 12
infectious diseases contain thimerosalas a preservative.
The MMR vaccine does not and never did contain thimerosal.
Varicella, (IPV) and PCV have also never contained thimerosal.
No scientifically substantiated association between the
administration of the MMR vaccine and development of AD.
Parents must be well educated that vaccines has nothing to do
with autism
This false belief came about because MMR is being given at
15months of age and the signs of autism are manifested at
18months.
Thimerosal was taken off from vaccines since 1990
BIOLOGIC BASIS Major brain structures implicated in autism: cerebellum
cerebral cortex, limbic system, corpus callosum, basal ganglia
and brainstem
Neurotransmitters: serotonin, dopamine, and epinephrine
Strong belief of Neurobiological alterations but cannot be
exactly pinpoint.
An interesting study was done wherein a Neuroscientist took
the head circumferences of infants diagnosed and suspected of
having Autism. He find out that there is an increase in the head
circumference of these children. His theory: this is because of
abnormal brain development or growth disregulation.
(Nelsons) Head circumference in AD normal or slightly small than normal a
birth until 2 months of age
Afterwards, show an abnormally rapid increase in head circumference
from 6-14 month of age
Increased brain volume in 2-4 years olds
o Increased volume of cerebellum, cerebrum and amygdala
o Marked abnormal growth in the frontal, temporal, cerebellar and
limbic regions of the brain
Followed by abnormally slow or arrested growth
o Areas of underdeveloped and abnormally circuitry in parts o
brains
Huge rise in prevalence rate
Globally affected
Raising figures
Environmental?
Result of unidentified risk
factors
Change in diagnostic
criteria
Improved detection
Rise in awareness
Better record keeping
More media attention
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Regression in overall behavior play, social skills,
communication
Emotional ability, out of control tantrums
Poor motor coordination
Fixate on objects (ie. Ceiling fans/bright lights of party)
Resists changes to specific routines/rituals
Self-injurious behavior
No fear of danger/pain
Dislikes to cuddle/be hugged
Unanimated facial expression or monotone voice
Extreme under/over activity
Diminished responses to pain (Nelson)
Lack of startle responses to sudden loud noises (nelson)
CLINICAL SIGNS ACCORDING TO NELSON
SOCIAL SKILLS
Impaired ability to engage in reciprocal social interactions
o abnormal eye contact
o failure to orient to name
o
failure to use gestures to point or show
o
lack of interactive playo
failure to smile
o lack of sharing
o lack of interest in other children
impairment in joint attention
deficits in empathy
deficits in understanding what another person might be thinking a
lack of theory of mind
VERBAL ABILITIES
range from being nonverbal to having some speech
speech have an odd prosody or intonation
characterized by echolalia, pronoun reversal, nonsense rhyming
PLAY SKILLS
little symbolic play
ritualistic rigidity
preoccupation with parts of objects
prefer solitary play
restrictive or repetitive interests or behaviors
ritualistic behavior
o often need to maintain a consistent, predictable environment
tantrum-like rages can accompany disruptions of routine
INTELLECTUAL FUNCTIONING
can vary from mental retardation to superior intellectual functioning in
select areas
some show typical development in certain skills and show areas of
strengths in specific areas
COMPREHENSIVE EVALUATION
Diagnosed by the clinical examination (Nelson)
DSM-IV criteria
Autism Diagnostic Interview Revised (ADI-R) and Autism Diagnostic
Observation Schedule (ADOS)gold standard diagnostic tools (Nelson)
Assorted checklist (eg. CARS, ADDS, M-CHAT, PDDST)
o Failure to meet age-expected language or social milestones are
important red flags for PDD (Nelson)
Cognitive testing
o Establish overall cognitive function and eligibility for services
(Nelson)
Adaptive skills testing
o Vineland Adaptive Behavior Scale (VABS) is essential to establish
priorities for treatment planning (Nelson)
DSM IV CRITERIA
When an individual displays 6 or more of 12 symptoms listed
across three (3) major areas:
o Social
o
Communication
o Behavior
DSM-IV-TR DIAGNOSTIC CRITERIA FORAUTISTIC DISORDER
A.
A total of six or more items from (1), (2) and (3) with at leas
two from (1) and one each from (2) and (3)
1. Evaluative impairment in social interaction as manifested
by at least two of the ff:
a. Marked impairment in the use of multiple nonverba
behaviors such as eye-toeye gaze, facial expression
body posture and gesture to regulate socia
interaction
b. Failure to develop peer relationships appropriate to
developmental level
c.
Lack of spontaneous seeking to share enjoymentinterests and achievements with others (eg. Lack o
showing, bringing or pointing out objects of interests
to other people)
d. Lack of social or emotional reciprocity (Note: in the
description, it gives one of the ff. as examples: not
actively participating in simple social play/games
prefers solitary activites or involving other activites
only as tools or mechanical aids)
2. Qualitative impairments in communication as manifested
by at least one of the following:
a. Delay in, or total lack of, the development of spoken
language (not accompanied by an attempt to
compensate through alternative modes o
communication such as gesture or mime)
b. In individuals with adequate speech, marked
impairment in the ability to initiate or sustain a
conversation with others
c. Stereotyped and repetitive use of language o
idiosyncratic language
d. Lack of varied, spontaneous make-believe play o
social imitative play appropriate to developmenta
level
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3. Restricted repetitive and stereotyped patterns of behavior,
interests, and activities, as manifested by at least one of
the following:
a. Encompassing preoccupation with one or more
stereotyped and restricted patterns of interest that is
abnormal either in intensity or focus
b.
Apparently inflexible adherence to specific,
nonfunctional routines or rituals
c.
Stereotyped and repetitive motor manners (e.g. hand
or finger flapping or twisting, or complex whole-body
movements)
d.
Persistent preoccupation with parts of objects
B. Delays or abnormal functioning in at least one of the following
areas, with onset prior to age 3 years: (1) social interaction, (2)
language as used in social communication, or 93) symbolic or
imaginative play
C. The disturbance is not better accounted for by Retts Disorder
or Childhood Disintegrative Disorder.
SPECIALIST/MULTIDISCIPLINARY TEAM
Developmental pediatrician
Pediatric neurologist
Child psychiatrist
Child psychologist
Speech pathologist
Occupational therapist
SPED teacher
Geneticist
Parent support groups
LABORATORY/DIAGNOSTICS
BAERhearing test
EEGsome have seizures
Neurological imaging
Metabolism screening (thyroid, lead)
Chromosomal studiesto rule out Fragile X syndrome
Critical Elements of the Evaluation (Nelson)
Detailed developmental history
o Review of communicative and motor milestones
Medical history
o Discussion of possible seizures, sensory deficits or other medical
conditions
Family history
o
Presence of other developmental disorders
Review of current and past psychotropic medications
o
Review of medication dosages and behavioral response, along
with adverse effects
PROBLEMS THAT MAY ACCOMPANY (ASD)
Sensory problems
Hypersensitivity to certain sounds, textures, tastes and smells
Sounds like vacuum cleaner, ringing of telephone, sudden
storm, waves lapping the shoreline will cause these children to
cover their ears and scream
Mental Retardation
Many children with ASD have some degree of menta
impairment
Seizures
Prevalence: 11-39%
HigHer prevalence if 42% with co-morbid mental retardation
and motor deficits
Onset of epilepsy in ASDs has two peaks: before 5 years of age
and adolescent
PATHOLOGY (Nelson)
Head circumference in AD normal or slightly small than normal a
birth until 2 months of age
Afterwards, show an abnormally rapid increase in head circumference
from 6-14 month of age
Increased brain volume in 2-4 years olds
o Increased volume of cerebellum, cerebrum and amygdale
o Marked abnormal growth in the frontal, temporal, cerebellar and
limbic regions of the brain Followed by abnormally slow or arrested growth
o Areas of underdeveloped and abnormally circuitry in parts o
brains
o
Most affected areas for higher-order cognitive, language
emotional and social functions
MANAGEMENT Primary goals of treatment are to maximize the childs ultimate
functional independence and quality of life
o Minimizing the core features of the disorder
o Facilitating development and learning
o Promoting socialization
o
Reducing maladaptive behaviorso Educating and supporting families
Treatment is primarily non medical
TREATMENT APPROACHES
Applied Behavioral Analysis (ABA)
DIR Method (Floortime)
Miller method
Relationship Development Intervention
Son-Rise
TEACCH Program
Discrete Trial Training (DTT)
CLINICAL THERAPIES
Speech and language therapy
Augmentative communication
Picture exchange communication
Sign language
Sensory Integration Therapy
Occupation Therapy
Physical therapy
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Occupational therapy is done first. If the child (70-80%) is looking at
you and is responding at you, thats the time you add speech
therapy. And if the child is ready for school, must assess if the child is
to go to a special school or regular school.
COMPLEMENTARY THERAPY (BIOLOGICAL)
Immunoregulatory interventions
o Dietary restriction of food allergens
o Administration of immunoglobulin or antiviral agents
Detoxification therapies
o chelation
Gastrointestinal treatment
o Digestive enzymes
o Antifungal agents
o Probiotics
o yeast-free diet, gluten/casein-free diet
o Vancomycin
Dietary supplements
o Vit. A, B6, B12, C, magnesium, folic acid, folinic acid,
dimethylglycine and trimethylglycine, inositol, fatty acids,
omega-3, various minerals and others
o Hyperbaric therapy
Therapy is still the best known management and not these niological
treatment methods.
Family Support
Respite
Support groups and web sites
Psychological services
Seminar and conference services
List ServicesAutism Society of the Philippines it is hard for parents to accept, as
if they have a child who is terminally ill. It is normal that parents
undergo the normal process of acceptance. If a parent cannot
accept, just lay your cards and explain the developmental problems
in intellect and language of the child that need to be corrected.
If it improved, good then. If not, that is Autism. Because some grow
normal but still have signs of autism like eye fleeting.
Pharmacotherapy
Pharmacological intervention targets associated comorbid conditions
and problematic behaviors
1. SSRIs mood and anxiety symptoms and compulsive-like
behaviors
2. Typical antipsychotics (Haloperidol) reducing stereotypy and
facilitating learning
3.
Atypical neuroleptics for symptoms of agitation, irritability,
aggression, self-injury and severe temper outbursts
4. Stimulants (in moderate doses) children with hyperactivity and
impusivity
5. -adrenergic agonists reduce hyperarousal symptoms including
hyperactivity, irritability, impusivity, and repetitive behavior
CURRENT LEVEL OF EVIDENCE
Biomedical Treatment Insufficient published evidence
need for treatment evaluation
studies, not for food selective
children
Tomatis Method Not supported by any published
research studies at present
Hyperbaric Oxygen Lack of well controlled
experimentations
Neurofeedback Needs more empirical research
Floor time (DIR) Looks promising, relatively new
but needs more research
Social skills A well structured group seems
very beneficial
Current Treatment Options
Early and Intensive Behavioral
Intervention (EIBI)
US Surgeon General has
recommended this a s effective
treatment
Treatment and Education of
Autism and RelatedCommunication Handicapped
Children (TEACCH)
National research council has
recommended this as plausibleintervention with positive
program evaluation date
Risperidone (Risperdal) Can be used as a treatmen
approach for problem behavio
only after a function based
approach was ineffective
PROGNOSIS
Most persons with PDD remain within the spectrum as adults
o Continue to experience problems with independent living
employment, social relationships, and mental health
Better prognosis is associated with higher intelligence, functiona
speech and less-bizarre symptoms and behavior.
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ATTENTION DEFICIT HYPERACTIVITY DISORDER
INTRODUCTION
Most common neurobehavioral disorder of childhood affecting school-
aged children
ADHD is a childhood onset neurobehavioral disorder which is
characterized by inattention, impulsivity, and hyperactivity.
ADHD Historic Timeline
1930: minimal brain damage
1968: hyperkinetic reaction of childhood (DSM-II)
1994: ADHD
2010: DSM-V
ADD (Attention Deficit Disorder) and ADHD are one and the same
PREVALENCE
Accounts for 30-40% of referrals
More common in boys than girls (5:1)
Estimated prevalence of children with ADHD is about 2-12%
(5.2%)
Can persist in adulthood:
o 8.10% of children have ADHD
o 9.6% of adolescents have ADHD
o 4.4 % of adults have ADHD
o Up to 65% of children with ADHD continue to experience
the DO into adulthood
Often underdiagnosed in children and adolescent
WHAT CAUSES ADHD?
Prevailing misconceptions such as:
o Kulang sa Pansin
o Temporary and will be outgrown
o Young, boytypical
o Laziness
o Diet: high in sugar intake
o Allergy
o Poor parenting, poor home life
o Poor teaching style in school
Hyperactivity can be normal for 2-4 years of age because this is the
run about stage but if this activity is impairing the childs functioning
then it is abnormal.
ADHD is heterogeneous behavioral DO with multiple possible
etiologies:
o Neurobiological factors
o Genetic origins (mean heritability is higher than
Schizophrenia)
o CNS insults
o Environmental factors (poor nutrition or exposure to Lead)
HERITABILITY OF ADHD
Mean heritability of ADHD is 0.75
There is a strong genetic component to ADHD
o 2 candidate genes: dopamine transporter gene (DAT1) and
dopamine 4 receptor gene (DRD4)
NEUROBIOLOGY OF ADHD
PET scan shows decreased cerebral metabolism in brain area
controlling attention
It is believed that there is a diminished blood flow to the frontal lobe,
which is the center of executive function, attention, and
concentration.
Nuerobiochemical Imbalance: Lack of Norepinephrine and
Dopamine. That is why medication plays a very important role in
management.
ENVIRONMENTAL CONTRIBUTION
Maternal drug use
Maternal smoking
Alcohol use during pregnancy
Prenatal or postnatal exposure to lead
Food colorings and preservatives have inconsistently been associated
with hyperactivity in previously hyperactive children
Psychosocial family stressors
Prenatal or perinatal insults (premature asphyxiated, stormy
course of neotatal)
Maternal depression
INTERPLAY OF ETIOLOGIC FACTORS
Exact etiology is unknown but it is believed that it is of
Neurobiological problem and environmental factors play an
important role.
SIGNS AND SYMPTOMS
Characterized by (CORE SYMPTOMS):
o Inattention
o Impulsivity
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o Hyperactivity
Other symptoms:
o Non compliance
o Impulse aggression
o Social interaction
o Academic efficiency
o Academic accuracy
o Irritable
o
Problems with sleep
EARLY INDICATORS
Diagnosis not made until 4years of age but early signs can be
seen
Before I was born, mom said I love to do cartwheels in her
belly
In infancy, may be characterized by unpredictable behavior,
shrill crying, irritability and overactivity
May show only brief periods of quiet sleep
Clinical manifestations may change with age
o Preschool children motor restlessness and, aggressive and
disruptive behavior
o Older adolescents and adults disorganized, distractible, and
inattentive symptoms
SYMPTOMS OF HYPERACTIVITY
Squirms and fidgets
Cannot stay seated
Runs or climbs excessively
Cannot play or work quietly
Is on the go or driven by a motor
Talks excessively
Pushing, hitting other children thinking that it is still part of play
Impatient
SYMPTOMS OF IMPULSIVITY
Blurts out answers
Cannot wait for his turn
Intrudes, interrupts others
SYMPTOMS OF INATTENTION
Carelessness
Difficulty sustaining attention in activity
Does not listen
Does not follow through with tasks
Is disorganized
Avoids/dislikes tasks requiring sustained mental effort
Loses important items
Easily distracted
Forgetful in daily activities
ADHD CLINICAL SUBTYPES
3 subtypes: (Nelson)
o ADHD, predominantly inattentive type
Often includes cognitive impairment
More common in females
o
ADHD, predominantly hyperactive-impulsive type
More common in males
o
ADHD, combined type
COMPARING BOYS AND GIRLS
BOYS GIRLS
Frequency of Referral more Less
Symptom recognition Earlier Later
ADHD type Combined (5:1) Pred. Inattentive (2:1)
Signs Externalizing:
aggression,
overreactivity
Internalizing:
Underachievement,
daydreaming
Females are diagnosed late because they manifest inattention than
the usual hyperactivity
ADHD DEVELOPMENTAL TREND BY AGE
As the child grows to adult, the hyperactivity and impulsivity would
decrease and what would remain is the Inattention.They usually
are impatient, restless, and disorganized.
ADHD: CO-MORBIDITY
Its presence is more the rulerather than the exception
Only ~30% will have pure ADHD
In those with co-morbidities:
o >80% have one co-morbidity
o 60% have at least 2 co-morbidities
Co-morbidities persist and more obvious when the patient
grows into an adult.
Most common co-morbidity is ODD (Oppositional Defiant
Disorder)
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DIAGNOSIS OF ADHD
History
o History of the presenting problems
o The childs overall health and development
o Social and family history
o Maternal and birth history
o Good family history (genetic) you can see if one of
parents have ADHD mother talking a lot or father
fidgeting
Interviews (parents, teachers and patient)
o Determine functional impairment at home and in
school/job setting
o Behavioral rating scale should be answered by both
parents and teachers because one of the criteria of
diagnosis is that this condition should be happening in two
settings
Rating scales to corroborate clinical symptoms
PE, VS, physical explanations for DO, secondary conditions,
drug contraindictation
DSM-IV TR criteria, ICD-10 criteria
Make assessment for co-morbid conditions
Interview should emphasize factors that might affect the development
or integrity of the CNS or reveal chronic illness, sensory impairments, or
medication use that might affect the childs functioning (Nelson)
DSM-IV CRITERIA
States that the behavior must be:
o developmentally inappropriate
o must begin before age 7 years
o must be present for at least 6 months
o must be present in 2 or more settings
o
must not be secondary to another disorder
Persistent pattern of inattention and/or hyperactivity or
impulsitivity
o
No. of symptoms (6 or more)
o Duration of symptoms (> 6 mos)
o Onset (before 7 y/o)
o Setting (2 or more settings)
o Severity (developmentally inappropriate)
o Impact (significant impairment in social, academic and
occupational functioning)
o Exclusion (other medical disorders)
Behavior Rating Scales
Useful in establishing the magnitude and pervasiveness of the
symptoms
Not sufficient alone to make a diagnosis of ADHD
1.
ADHD Diagnostic Rating Scale
2.
Conner Rating Scales (parent and teacher)
3. ADHD Index
4. Swanson, Nolan and Pelham Checklist
5. ADD-H: Comprehensive Teacher Rating Scale
Conners is the most commonly used
Physical Examination and Laboratory Findings No laboratory tests available
Presence of HPN, ataxia or thyroid DO should prompt further diagnostic
evaluation
Impaired fine motor movement and poor coordination and other soft
signs are common
o finger tapping
o alternating movements
o
finger-to-nose
o skipping
o tracing a maze
o cutting paper
STANDARD ADHD TREATMENTEDUCATION
Understanding the DO
o Medical cause
o Not due to parenting
Environmental restructuring
o Classroom changes
o ADHD-friendly modification in family, work, leisure
activities
o Structure, list, delegating
Parent support groups: www.chadd.org or www.add.org
Educate parents that this condition is inborn and that poo
parenting is not the cause of the problem, how to handle thechild
PSYCHOSOCIAL INTERVENTION
Parent education
o Reinforce positive behavior and correct negative behavior
o Establish and maintain house rules
Academic Skill Training
o Focus on time management, study skill and following
directions
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Social Skill Training
o Target specific behaviors (e.g. playground aggression)
Behavioral management in the time frame of 8-12 sessions
o Stress-conflict resolution
ADHD children does not have to be placed in special schools because
actually these children are very smart with normal IQ unless in cases
with concomitant intellectual disbilities
MEDICATION
Remains as one of the most successful treatment for child with
ADHD
As effective as standard therapy treatment. Dr. Eusebio have
patients in the province with no therapy but on medication and
they are doing alright.
Medications increases the neurotransmitter in the synapses
MEDICATIONS APPROVED BY FDA
Psychostimulant (FIRST LINE)
Amphetamine preparation
o
Addreallo Dexedrine
Methylphenidate preparation (best)
o Ritalin
o MPHOros (Concerta)
o Transdermal delivery system (patch)
Psychostimulants found to improve core symptoms of ADHD
(inattention, impulsivity and hyperactivity). It also improve other
symptoms such as noncompliance, impulsive aggression, social
interactions, academic efficiency, academic accuracy and family
dynamics
Limitations to Psychostimulants
Tolerability issues
o Insomnia, irritability, headache, appetite suppression
o Parent/patient perception of mood and personality
change on medication
o Adverse effect on height and weight
o In other countries used as diet pills that is why it is
regulated
Co-morbid conditions (tics, anxiety) aggrevated
Controlled substance concerns
o Social stigma
o Diversion and abuse potential (DEA Schedule II drugs)
o Prescribing Inconvenience
Noradrenergic Reuptake Inhibitor (SECOND LINE)
Atomoxetine (Strattera)
Giving psychostimulant to somebody who Is already hyperactive, it is
postulated that in ADHD the stimulatory portion of the brain is the
only one activated and the inhibitory center is dormant or asleep
The psychostimulants will work on the inhibitory center to correct
the imbalance.
Alternative Medications (Not Approved by FDA)
Antidepressants
o Bupropion
o Imipramine
o Nortriptyline
Alpha-2 Adrenergic Agents/Antihypertensives
o Clonidine (used prior to Methylphenidate but will only cure
the impulsivity and not the hyperactivity)
o Guanfacine
Arousal Agents
o Modafinil
Non-Traditional Therapies for ADHD
Dietary management
Bio/Neurofeedback Therapy
Tomatis Method
All are controversial and alternative treatments!!!
BURDEN OF ADHD
Impacts on all aspects of life
Childhood: Impair peer relationship, academic limitation
socioemotional problem
Other children do not involve ADHD child because they are too
aggressive
Academic limitations because as more and more academic skills
need to learn the lack of attention impairs the receptivity to
learning, careless mistakes and not review test exams
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Adolescents: at risk of getting into risk taking behaviors like
alcohol and drug abuse, motor and vehicular accidents
Adults: moving from one job to another, or relationship from
one to another.
Adult Outcome of Children with ADHD
Adults who function fairly well: 30%
Adults who continue to have significant problems with
concentration, impulsivity and social interaction: 50-60%
Adults who have psychiatric or antisocial problems or both: 10-
15%
ADHD is not yet curable but certainly is manageable!
-----------------------------END----------------------------------