ADHD Through The Life Cycle by Humberto Nagera M.D. Professor of Psychiatry, University of South Florida. Professor Emeritus, University of Michigan. Training and Supervising Psychoanalyst, Tampa Bay Psychoanalytic Institute. Director, The Carter-Jenkins Center. There are 5 hyperlinks in this presentation. They concern description of the drugs in more detail and are indicated by an underlined word in white. Occasionally the link may be 2 or 3 pages and this is indicated by a (next) at the end of the page. The return link is in the last page if there is more than one to the given subject. The last link goes from page 25 to 30 (which is The End page, avoiding going a second time over the same material).

ADHD Through The Life Cycle: Myths About ADHD 1) Only affects children 2) Disappears in adolescence 3) Does not affect adults 4) Ritalin has paradoxical effects in children not in adults 4) That is why people thinks Ritalin does not work in adults, i,e it does not have a paradoxical effect in adults. NOT TRUE.

ADHD Through The Life Cycle: Myths About ADHD(cont) 5) Consequently it does not work in adults 6) Dangerous drug because possibility of addiction

ADHD Through The Life Cycle History of the Disorder First called minimal brain damage Afterwards called minimal brain dysfunction Next called ADD Finally called ADHD

ADHD Through The Life Cycle Etiology of the Disorder ADHD is a genetic disorder Involves possibly several genes They have a tendency to segregate together This may mean they are close to one another Genetic disorder except in some very rare cases of Von Economo’s encephalitis. The disorder starts at birth and frequently in utero. These children move and kick a lot while in utero. Because of that, complications at birth are not uncommon, cords around the neck, wrong presentation etc

ADHD Through The Life Cycle Etiology of the Disorder Runs in families Manifests itself with different degrees of severity in a given generation Manifest itself with different degrees of severity in each one of the various generations

ADHD Through The Life Cycle Some General Characteristics Some have learning disabilities (5-10%) Some have soft neurological signs Watch for Tourette’s disorder 1 or 2% may be co-morbid with BD As they grow older can become ODD, CD etc Some. if untreated beyond evolving to Oppositional Defiant Disorders and later Conduct Disorders find their way to jail where they are highly represented and generally untreated. Sometimes is very clear since birth. In those cases these babies are colicky, irritable, have crying spells, sleep problems, are difficult to comfort etc.

ADHD Through The Life Cycle Some General Characteristics Lack of social skills, unpopular, need to be first Needs are imperative, now, can not wait Lower threshold for stimuli (ADHD a misnomer) Writing a problem, reversal of letters etc

ADHD Through The Life Cycle Symptoms In Children Distractability, inability to pay attention Hyperactivity (more in boys than girls) Impulsivity (doing things without thinking of the consequences) I will add irritability (very short fuses) The degree to which each one of the components of the syndrome manifest itself is very variable as is the proportions in which they combine themselves i e some are only distractable while others more hyper than distractable etc. Short attention span except for computers, Nintendo type of games, etc. If he can pay attention to computer games why not at school?

ADHD Through The Life Cycle Adult Characteristics 1) ADHD persist into adulthood 75% of the time 2) Up to 4% of adults suffer from it 3) It can be quite crippling, according to severity of the disorder

ADHD Through The Life Cycle Adult Characteristics 4) Diagnosis similar to that in children but: a) At times hyperactivity is better controlled b) In adults nearly as many females as males

ADHD Through The Life Cycle Adult Characteristics c) Early conflicts at school are the same but with a change of scenarios. School becomes the workplace, peers-spouses, teacher-bosses etc 5) Treatment is similar to that of children

ADHD Through The Life Cycle Adult Characteristics 6) Watch for alcohol and or drug abuse (common) 7) Watch for substance abusers: a) Interview wife b) Call their physician, pastor etc c) Offer Desipramine

ADHD Through The Life Cycle Symptoms Of Adults 1) Distractability in different degrees 2) Hyperactivity present but better control sometimes 3) Impulsivity (acting without thinking) 4) Irritability, hot temper, affective lability 5) Significant stress intolerance

ADHD Through The Life Cycle Drugs Used For Treatment WARNING: Do not use Cylert as first line Drugs most used are various forms of: a) Ritalin (methylphenidate)(Various forms, Concerta) b) Dextro-amphetamines (Various forms) c) Tricyclics and/or antihipertensives d) Wellbutrin, Clonidine, neuroleptics etc e) Monoamine oxidase inhibitors (effective but very dangerous, particularly in children) f) Focalin and Ritalin La g) Atomoxetine (Strattera) Cylert can damage the liver and cause death particularly in the young. Not recommended since deaths are reported. Abbot itself said not to use as a first line medication. Ritalin can be given in doses of 5-20 mgs 2 to 4x q.d. It comes in straight doses of 5, 10, and 15 mgs. There is too a 20 mgs slow release. Ritalin can thus be given as well with a doses of straight release plus 20-40 mgs of slow release. A new form of slow release Ritalin is Concerta. Combines straight release and slow release in a new and very effective delivery system. Concerta comes in 18, 36, and 54 mgs. One can combine if necessary 54+18 mgs to make 72 mgs for example. Last frequently 10-12 hours and there are not the up and downs observed when straight ritalin or dexedrine is given. Metadate CD is another form of extended release methylphenidate. Doses goes from 20 –60 mg. Presentation is 20 mg. First peak about one and a half hours after taken it with another peak at 4.5 hour after which it starts to go down. Thus it last 5-6 hours, rarely more. Dextroamphetamines such as Dextrostat or Dexedrine come in 5 mgs of straight release. Can be given as such in variable doses (according to severity of symptoms) 2x or 3x a day. Dexedrine comes in slow release as well, in doses of 5, 10, 15 mgs. Straight and slow release are combined with effects lasting 8-9 hours, rarely more. Benzedrine a dextro and levo form of amphetamine was used successfully 20 years ago. Was abandoned for the false believe that the levo component made amphetamines addictive. Hence the dextroamphetamines but they are just as addictive, except for people with ADHD. Tricyclics such as Norpramine, Desipramine, Nortriptyline had been used though the latter less so. Dirty drugs with many side effects. Levels need to be monitored, as well as cardiovascular side effects. Some deaths in children reported on tricyclics? Antihipertensives are mostly clonidine (Catapres), guanfacine(Tenex), and some beta blockers (Pindolol). Catapress dosis is 0.1 mg up to 3x a day. Last dosis at h.s. can be 0.15 mg, but doses must be spaced not less than 6 hours. There is a transdermal patch Catapress TTS(1,2, or 3) programmed to deliver from 0.1-0.3 each day for a week according to size of the patch Guanfacine (Tenex) dosis is 1-3 mg q.d, must be spaced too. Monoamines such as Parnate or Eutonyl though effective are not recommended for obvious reasons, particularly in children or adolescents. Wellbutrin is not nearly as effective as psychostimulants in most cases. Blocks weakly serotonin and norepinephrine uptake. A weak dopamine agonist. Slight noradrenergic and dopaminergic effects. Neuroleptics should very rarely be used if ever. Focalin(Novartis) is dexmethylphenidate HCl. It is on the market now. Tablets are 2.5, 5 and 10 mg. Said to have been given at 3.5 and 5.5 hours interval (twice a day). See no reason to change to it. Atomoxetine (Lilly): New non-stimulant drug, not yet in the market. May be of interest being a non-stimulant perhaps it could be given in late afternoon or early evening.

ADHD Through The Life Cycle Drugs Used For Treatment Ritalin is classified as a psychostimulant drug Comes in several forms: a) Straight Ritalin (5, 10, and 15 mg) (3 ½ H) b) SR Ritalin (Ciba 20 mg) (not recommended) c) Metadate CD, ER, (Celltech 20 mg) (5-6 H) d) Concerta(ER) (18, 27, 36 and 54 mg) ( 11- 12 H) e) FocalinTM (2.5, 5, 10 mg) (Out recently) f) Ritalin LA (20, 30, 40 mg) ( 7 hours ?)(Sprinkle) Concerta warns about using this drug if you have glaucoma.

ADHD Through The Life Cycle Drugs Used For Treatment Dextro-amphetamines: 1) Most used straight release are: a) Dexedrine (5mg), (4 ½ H) b) Dextrostat (5 and 10 mg) (4 ½ H) c) Adderall (5, 10, 20 mg) (4 ½ H) 2) Slow releases: a) Dexedrine SR (5, 10 and 15 mg) (7-10 H) b) Adderall XR (10, 20 and 30 mg capsules) (7-10 H) If anyone was on MAOI’s a two week period wash out is necessary before starting amphetamines.

ADHD Through The Life Cycle Drugs Used For Treatment Tricyclic antidepressants: 1) Longer duration of action (once daily dosing) 2) No rebound or insomnia problems 3) Can monitor plasma drug levels (for safety and compliance) 4) No risk of abuse, small doses of 10-25 mg 5) Some death reports in children with TCA’s (next)

Tricyclic Antidepressants (cont) Those more frequently used in the past were: a) Norpramin (imipramine+desipramine) -Dirty, many side effects b) Better to use Desipramine (less side effects, may respond by third day) c) Nortriptiline (not generally used) Always monitor cardiovascular side effects

ADHD Through The Life Cycle Drugs Used For Treatment The Use of Catapres (Clonidine), and Tenex: 1) Clonidine is an imidazoline derivative used as antihypertensive agent 2) Reduce the activation or arousal of ADHD, Tourette’s syndrome and aggression 3) Used in highly irritable, impulsive and aggressive children (next)

ADHD Through The Life Cycle Drugs Used For Treatment 4) On occasion Clonidine is given with Ritalin or Dexedrine with optimal results 5) Useful in motor tics, overactive ADHD, growth impairment 6) Not useful to control distractability itself 7) Helps sleep if taken in late afternoon (next)

ADHD Through The Life Cycle Drugs Used For Treatment 8) Can be taken up to 3x q.d ( 6 hours interval) at doses of up to 0.1 mg (total of 0.3-0.3 ½ mg) 9) Major side effect is sedation starting 30-60’ after doses is taken 10) Excretion half life 8-12 H but very variable 11) May take 2 - 4 weeks to see response (beyond sedation) (next)

ADHD Through The Life Cycle Drugs Used For Treatment 12) Patches can be used delivering 0.1-0.3 mg q.d for a week according to size of patch 13) Guanfacine (Tenex) can be given in doses of 1-3 mg q.d (6 hours interval between doses) 14) Guanfacine (Tenex) has the same indications of Clonidine

New Drug on the Market Atomoxetine (Strattera) is a re-uptake inhibitor of norepinephrine . It is not a psychostimulant. Best doses seems to be 1.2 mg/kg/day Now approved. Limited experience with it. Does not exacerbate tics. Covers patient 24 hours. No safety concerns as with tricyclics. Not controlled by FDA Side effects: Decreased appetite, nausea, loss of weight, somnolence, etc. Loss of libido (7%). Non-addictive.

The End Questions?

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