TREATING ADHD: A Parent’s Guide Lisa B. Campbell, MD Medical Director, ADHD Specialty Clinic Children’s Mercy Hospitals and Clinics

Things that don’t (or rarely*) cause ADHD Sugar Allergies Immunizations Food additives* Environmental toxins* Head injuries*

DSM Symptoms of ADHD Inattention Often does not pay attention to details/ makes careless mistakes in schoolwork or other activities Often has trouble keeping attention on tasks or play activities Often does not seem to listen when spoken to directly Often does not follow instructions and fails to finish schoolwork, chores, or other tasks Often has trouble organizing activities

DSM Symptoms of ADHD Inattention (cont) Often avoids, dislikes, or doesn't want to do things that take a lot of mental effort (such as schoolwork or homework) Often loses things needed for tasks and activities Is often easily distracted Is often forgetful in daily activities

DSM Symptoms of ADHD Hyperactivity Often fidgets with hands or feet or squirms in seat when sitting still is expected Often gets up from seat when remaining in seat is expected Often excessively runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless) Often has trouble playing or doing leisure activities quietly Is often "on the go" or acts as if "driven by a motor" Often talks excessively

DSM Symptoms of ADHD Impulsivity Often blurts out answers before questions have been finished Often has trouble waiting turn Often interrupts or intrudes on others

What is ADHD? Neurobiological disorder Decreased activity in parts of brain that control: Problem solving Attention Reasoning Planning

ADHD and the Brain

Copyright © 2012 American Medical Association. All rights reserved. From: Meta-analysis of Functional Magnetic Resonance Imaging Studies of Inhibition and Attention in Attention-deficit/Hyperactivity Disorder:  Exploring Task-Specific, Stimulant Medication, and Age Effects JAMA Psychiatry. 2013;70(2):185-198. doi:10.1001/jamapsychiatry.2013.277 Figure Legend: Figure 1. Inhibition tasks and attention tasks. A, All inhibition tasks together. Regions of decreased (red and orange) and increased (blue) activation in patients with attention-deficit/hyperactivity disorder compared with healthy controls. Decreased activation in patients with attention-deficit/hyperactivity disorder relative to healthy controls is shown in the right inferior prefrontal cortex (IFC) extending into the insula, in a cluster comprising the supplementary motor area (SMA) and the cognitive division of anterior cingulate cortex (ACC), in the left caudate extending into the putamen and insula, and in the right mid-thalamus. B, Attention tasks. Decreased activation in patients with attention-deficit/hyperactivity disorder is shown in the right dorsolateral prefrontal cortex (DLPFC), in the left putamen and globus pallidus, in the right posterior thalamus (pulvinar) and caudate tail extending into the posterior insula, in the right inferior parietal lobe, and in the precuneus and superior temporal lobe. Increased activation in patients with attention-deficit/hyperactivity disorder relative to healthy controls was seen in the left cuneus and in the right cerebellum. Date of download: 6/18/2013 Copyright © 2012 American Medical Association. All rights reserved.

Copyright © 2012 American Medical Association. All rights reserved. From: Meta-analysis of Functional Magnetic Resonance Imaging Studies of Inhibition and Attention in Attention-deficit/Hyperactivity Disorder:  Exploring Task-Specific, Stimulant Medication, and Age Effects JAMA Psychiatry. 2013;70(2):185-198. doi:10.1001/jamapsychiatry.2013.277 Figure Legend: Figure 2. Inhibition tasks. A, All inhibition tasks together, with cross sections showing regions of decreased activation in patients with attention-deficit/hyperactivity disorder compared with healthy controls. Shown are the right inferior prefrontal cortex, insula, right thalamus, left caudate, left putamen, and left insula. B. Motor response inhibition only, showing the right inferior prefrontal cortex and insula, right supplementary motor area and anterior cingulate cortex, right thalamus, left caudate, and right fusiform gyrus. C, Interference inhibition only, showing the right inferior prefrontal cortex and insula, left anterior cingulate cortex, right caudate (head), and left posterior parietal lobe and posterior insula. The right side of the image corresponds to the right side of the brain. Distance from the anterior or posterior commissure is indicated in millimeters for the z coordinate. Date of download: 6/18/2013 Copyright © 2012 American Medical Association. All rights reserved.

Diagnosis of ADHD No single test or group of tests How child is doing at home and at school academically, emotionally and socially Rating scales Symptoms Performance or function Report cards Behavior reports Interview

Treatment for ADHD Medical Behavioral Educational About ADHD About educational interventions

Proven treatment for ADHD Medication Behavioral therapy Gold standard= Combination of both

Medication Treatment for ADHD NOT used to control behavior Used to improve symptoms

Medication Treatment of ADHD Stimulants Methylphenidate Amphetamine Non-stimulants Guanfacine/Intuniv Clonidine/Kapvay Atomoxetine (Strattera)

Medication Treatment of ADHD One-size-fits-all approach doesn’t work Each child’s response is individual Medication Dose Side effects More than one medication and/or dose may be tried

Stimulants Come in a variety of forms Tablets Chewable tablets Capsules Sprinkles Liquids Skin patches

Stimulants Methylphenidate Short-acting (3-4 hours) Ritalin Methylin (tablet, chewable tablet or solution) Focalin (dexmethylphenidate)

Stimulants Methylphenidate Intermediate-acting (6-8 hours) Methylin ER Metadate ER Ritalin SR Metadate CD Ritalin LA

Stimulants Methylphenidate Long-acting (8-12 hours) Concerta Focalin XR (dexmethylphenidate) Daytrana* Quillivant XR (solution) * Duration can be longer

Stimulants Amphetamine Short-acting (4-5 hours) Dexedrine Adderall (mixed amphetamine salts) Procentra (solution)

Stimulants Amphetamine Long-acting Dexedrine Spansule Vyvanse (lisdexamfetamine) Adderall XR (mixed amphetamine salts)

Stimulants First line Initial response rate 65-75% with single stimulant 85% if both classes tried No difference head-to-head between classes

Stimulants Excellent evidence for short-term improvement Core symptoms Academics Efficiency and accuracy Tasks attempted and completed Homework completion Behavior Noncompliance Aggression Poor social interactions Disruptive behavior Driving performance (in lab)

Stimulants Longer term F/U at 8 years (MTA study) showed no differences Problems Only definitely ON medication for 14 mos Not “active” treatment data Only 32% had taken medicine for more than 50% of the days in the previous year.

Stimulants Non-core symptoms may not improve Injuries Social functioning Educational outcomes

Stimulants: Side Effects Most common Decreased appetite and weight loss Trouble falling asleep Headache Stomachache Personality changes Irritability Anxiety Cognitive dulling Over focus Rebound Usually mild and respond to waiting, changes in dose, timing or type of medication

Stimulants: Side Effects Heart Pulse < 5 bpm BP < 5 mmHg No serious events—no increased risk of sudden unexplained death without family history No need for EKG unless Existing heart disease Family history

Stimulants: Side Effects Growth Reduced growth rate first 4-12 months Generally not significant Responds to medication holidays or non-stimulants

Stimulants: Side Effects Tics Short-term studies don’t show significant increase in new onset or worsening of existing. Tics may improve. Long-term appear to be safe.

Non-stimulants Atomoxetine (Strattera) Antidepressant Works 50-60% of time Takes 6-12 weeks Side effects Abdominal pain/nausea/appetite loss Sedation Aggressive behavior Liver toxicity Sometimes used if co morbid anxiety or substance abuse present

Non-stimulants Guanfacine/Intuniv Blood pressure medication Alone or as add-on therapy Alone Intuniv works 40-80% of time Adjunctive Intuniv works additional 30-40% of time Guanfacine immediate-release (Tenex) taken 2X/day Guanfacine XR (Intuniv) taken 1X/day Side effects Sleepiness/fatigue (often improves over time) Abdominal pain Dizziness/low blood pressure Irritability

Non-stimulants Clonidine/Kapvay Blood pressure medication Alone or as add-on therapy Alone Kapvay works ~70 % of time Clonidine IR (Catapress) taken 2-4 X/day Clonidine XR (Kapvay) taken 2X/day Side effects Sleepiness/fatigue (often improves over time) Headache Abdominal pain Constipation Dizziness/low blood pressure

Nothing works? Is it really ADHD? Could it be something else or in addition to ADHD? Depression Anxiety ODD/CD Learning disability Is there a genetic problem with medication response? IPTC NEEDS BEHAVIOR THERAPY!

Resources: Websites National Institute of Mental Health http://www.nimh.nih.gov/health/publications/attention-deficit-hyperactivity-disorder/index.shtml CHADD http://www.chadd.org CDC http://www.cdc.gov/ncbddd/adhd/ American Academy of Child and Adolescent Psychiatry http://www.parentsmedguide.org/ParentGuide_English.pdf American Academy of Pediatrics http://patiented.aap.org/content2.aspx?aid=6050 http://pediatrics.aappublications.org/content/suppl/2006/02/15/108.4.1033.DC1/P2_1033.pdf ADDvance: Answers to your Questions about ADD (ADHD) http://www.addvance.com/ http://www.cldinternational.org/ Learning Disabilities Association of America http://www.ldanatl.org/ MPACT Parent Training and Information www.ptimpact.org

Resources: Books and Magazines ADHD: What Every Parent Needs to Know, 2nd Edition, American Academy of Pediatrics Taking Charge of ADHD, 3rd edition, Russell A. Barkley, PhD