1. ADHD and Teenagers An Approach Henry Maguire MD Director Pediatric Neurology Geisinger Medical Center

2. ADHD – DO YOU BELIEVE? Is this real or just a big pharma marketing tool for their medications? Cross cultural studies support the idea that ADHD this is not an American phenomena Medication does work

3. ADHD Do You Believe? Neuroimaging- ADHD patients have smaller prefrontal and basal ganglia structures along with smaller posterior inferior cerebellar vermis Neuropsychological studies- frontal cortical and basal ganglia circuits key for executive function/attention/inhibition fMRI- abnormal activation in striatum/prefrontal cortex/anterior cingulate cortex

5. ADHD Do You Believe? We have known that effective pharmacologic treatment has existed for ADHD syndrome for years 1937 Charles Bradley, working at Bradley Children’s hospital in Rhode Island, treats 30 behaviorally disturbed children with benzedrine and in 14 notes spectacular results Benzedrine had been used to treat post pneumoencephalogram headaches

6. ADHD Do You Believe? “To see a single daily dose of benzedrine produce a greater improvement in school performance than the combined efforts of a capable staff working in a most favorable setting, would have been all but demoralizing to the teachers, had not the improvement been so gratifying from a practical viewpoint”

11. ADHD Do you Believe?

12. Medication for Attention Deficit–Hyperactivity Disorder and Criminality Paul Lichtenstein, Ph.D., Linda Halldner, M.D., Ph.D., Johan Zetterqvist, M.Ed., Arvid Sjölander, Ph.D., Eva Serlachius, M.D., Ph.D., Seena Fazel, M.B., Ch.B., M.D., Niklas Långström, M.D., Ph.D., and Henrik Larsson, M.D., Ph.D. N Engl J Med 2012; 367:2006-2014November 22, 2012DOI: 10.1056/NEJMoa1203241November 22, 2012

13. Using Swedish national registers, we gathered information on 25,656 patients with a diagnosis of ADHD, their pharmacologic treatment, and subsequent criminal convictions in Sweden from 2006 through 2009. We used stratified Cox regression analyses to compare the rate of criminality while the patients were receiving ADHD medication, as compared with the rate for the same patients while not receiving medication.

14. Results As compared with nonmedication periods, among patients receiving ADHD medication, there was a significant reduction of 32% in the criminality rate for men (adjusted hazard ratio, 0.68; 95% confidence interval [CI], 0.63 to 0.73) and 41% for women (hazard ratio, 0.59; 95% CI, 0.50 to 0.70). The rate reduction remained between 17% and 46% in sensitivity analyses among men, with factors that included different types of drugs (e.g., stimulant vs. nonstimulant) and outcomes (e.g., type of crime).

15. Conclusions Among patients with ADHD, rates of criminality were lower during periods when they were receiving ADHD medication. These findings raise the possibility that the use of medication reduces the risk of criminality among patients with ADHD.

16. ADHD Do You Believe? If you don’t then not much to say If you do then the question is how do we diagnose KISS- Keep It Simple Stupid

17. ADHD Defined DSM V- 2 symptom domains hyperactivity and inattention INATTENTION-poor attention to detail/difficulty sustaining attention/does not follow through on instructions/difficulty organizing tasks/avoids sustained mental effort (except video games)/loses things/easily distracted/forgetful

18. ADHD DEFINED HYPERACTIVITY-fidgets/leaves seat when expected to sit/runs about, climbs excessively, feels restless/ difficulty playing quietly/always on the go (Energizer Bunny)/ talks excessively Hyperactivity/Inattention-18 symptoms, 6 in each domain- that’s your diagnosis

19. ADHD Defined DSM V Small change- used to be symptoms are present before age 7 Now several of these symptoms were present before age 12 I feel this is a key point NOT AN ACQUIRED ILLNESS

20. ADHD Defined-Office Tools Conners Scale/Vanderbilt Scale- Good for picking up hyperactive and inattentive sx- can miss comorbid psychiatric morbidities Google “ ADHD rating scales children” http://www2.massgeneral.org/schoolpsychiat ry/screeningtools_table.asp

21. Teenage ADHD

22. What Is The Concern With Making a New Diagnosis of ADHD? Excuse for poor performance Not addressing other issues The need for pharmacologic treatment

23. ADHD- Differential Diagnosis Depression- not helped by stimulants Anxiety- worsened with stimulants Sleep Disorder- worsened with stimulants Substance Abuse-not a great idea to give stimulants Nutritional Deficiency- not helped Hypomania/Mania – worsened with stimulants

24. What is the Concern with making the Diagnosis? –Excuses For Performance Is performance a problem? Need to review report cards If the patient is suddenly not doing well after previously being a good student this requires some looking into (ADHD a life long condition) Family strife School strife Switching school More challenging curriculum

25. What is the Concern with making the Diagnosis?- Excuses for Performance New medical problem, seizures, concussion, pregnancy Learning to read (1 st through 3 rd grade) vs reading to learn (4 th grade and beyond) How much time is spent on homework- for the college bound 10 minutes per grade per night and doing it in school does not count (homework log)

26. How Do I Treat ADHD Stimulants are the best- methylphenidate and methamphetamine (Ritalin and Adderall) Rapid onset and offset Side effect profiles identical but individuals may tolerate one and not the other One can work and the other may not Chevy vs Ford

27. How Do I Treat ADHD/ Stimulants Irritability /nausea/headache/ sleep disturbance/tics Need to monitor height/ weight/ blood pressure I do not get baseline EKG Do get a cardiac history (preexisting heart disease/family hx of heart disease below age 25?) What about seizure history?

28. How Do I Treat ADHD-Stimulants Go low go slow Methylphenidate 0.5 to 1.5 mg/kg/day –to a point Adderall 0.25 to 0.75 mg/kg/day –to a point Consider rx for homework only (early session) Start with long acting form Adderall XR or Concerta to avoid afternoon crash and /or need to give med in school Reassess after ~ 2 weeks on med

29. How Do I Treat ADHD Strattera/Atomoxetine Selective norepinephrine reuptake inhibitor More effective for inattention than hyperactivity Effect not immediate Need to monitor LFT’s Not the same punch as stimulants but a good second line - ~70% response rate for stimulant failures BID dosing more effective

30. How Do I Treat ADHD/Other Bupropion Guanfacine (Tenex) Modafinal

31. ADHD Adolescents- Important Points It could be undiagnosed (particularly ADD girls) or blamed/not recognized as part of learning disability syndrome However it is a preexisting condition- not acquired High response rate to stimulants (80%) Define “response”

32. How Do You Know It is Helping? Teacher Assessments- blinded? Grades Parent observations