ADHD Child to Adult Cindy Ruttan DO 2008

64
ADHD Child to Adult ADHD Child to Adult Cindy Ruttan DO 2008 Cindy Ruttan DO 2008 Kansas Osteopathic Kansas Osteopathic Conference Conference OVPK KS OVPK KS

description

 

Transcript of ADHD Child to Adult Cindy Ruttan DO 2008

Page 1: ADHD Child to Adult Cindy Ruttan DO 2008

ADHD Child to AdultADHD Child to Adult Cindy Ruttan DO 2008Cindy Ruttan DO 2008

Kansas Osteopathic ConferenceKansas Osteopathic Conference

OVPK KS OVPK KS

Page 2: ADHD Child to Adult Cindy Ruttan DO 2008

Key points to coverKey points to cover Symptoms/ HistorySymptoms/ History Who it effects-agesWho it effects-ages Collecting informantsCollecting informants Rule out diagnosisRule out diagnosis Treatment optionsTreatment options

Behavioral Behavioral MedicationsMedications

Page 3: ADHD Child to Adult Cindy Ruttan DO 2008

ADHD is like---ADHD is like---

I stopped to think, and forgot to I stopped to think, and forgot to start again.start again.

  

I was trying to daydream, but my I was trying to daydream, but my mind kept wanderingmind kept wandering. .

Page 4: ADHD Child to Adult Cindy Ruttan DO 2008

What is ADHD ?What is ADHD ?

Neuro- Behavioral Disorder Neuro- Behavioral Disorder Inattention-( executive functions) Inattention-( executive functions) HyperactivityHyperactivity ImpulsivityImpulsivity

Speculate: Dopamine and NE Speculate: Dopamine and NE dysregulationdysregulation

Affects 7-12% of pediatric group Affects 7-12% of pediatric group pop.pop.

High chance for Co-morbidityHigh chance for Co-morbidity Costly due to ER use, injury and Costly due to ER use, injury and Hospital useHospital use..

Page 5: ADHD Child to Adult Cindy Ruttan DO 2008

ADHD Review HistoryADHD Review History

Core criteria DSM-III: Core criteria DSM-III: 3 separate symptom 3 separate symptom areasareas

DSM-III-R DSM-III-R one long list one long list

DSM-IV DSM-IV two core dimensionstwo core dimensions

Page 6: ADHD Child to Adult Cindy Ruttan DO 2008

ADHD and DSM IV criteriaADHD and DSM IV criteria

Concerned by …may change in Concerned by …may change in future DSM’s.future DSM’s.

1.1. Age of onset- ? 7 yearsAge of onset- ? 7 years

2.2. Age appropriate Symptoms are Age appropriate Symptoms are needed for helping diagnose needed for helping diagnose disorder from Child/ Adol/ disorder from Child/ Adol/ AdultsAdults

3.3. Various inputs needed –they Various inputs needed –they can conflictcan conflict

Page 7: ADHD Child to Adult Cindy Ruttan DO 2008

MOATMOATADHD DiagnosisADHD Diagnosis MMovement excessive ovement excessive (Hyperactive)(Hyperactive)

OOrganization problems rganization problems (difficulty finishing (difficulty finishing tasks)tasks)

AAttention problemsttention problems TTalking impulsivelyalking impulsively

Meet criteria of 6 of 9 symptoms, present prior to age 7yrs and Meet criteria of 6 of 9 symptoms, present prior to age 7yrs and present in 2 or more settings.present in 2 or more settings.

The Psychiatric Interview 2The Psychiatric Interview 2ndnd ed Carlat ed Carlat

Page 8: ADHD Child to Adult Cindy Ruttan DO 2008

Children's ADHDChildren's ADHD Review of past 10 yearsReview of past 10 years

Reviews in Child Adolescent Reviews in Child Adolescent Psychiatry (Williams and Psychiatry (Williams and Wilkins) Pg 9-17. by Wilkins) Pg 9-17. by Dennis Cantwell MDDennis Cantwell MDReprint from the J. of Reprint from the J. of the American Academy of the American Academy of Child and Adolescent Child and Adolescent PsychiatryPsychiatry..

Page 9: ADHD Child to Adult Cindy Ruttan DO 2008

ADHD Natural HxADHD Natural Hx 30% Developmental Delay30% Developmental Delay 40% Continual Display40% Continual Display

Internalizing disordersInternalizing disordersDepression Depression AnxietyAnxiety

30% Developmental Decay30% Developmental DecayExternalizing disordersExternalizing disorders

ODDODDCDCD

Page 10: ADHD Child to Adult Cindy Ruttan DO 2008

ADHD info from 10 year ADHD info from 10 year reviewreview Core symptoms may change over Core symptoms may change over time. Consider the younger one time. Consider the younger one presented the more persistent presented the more persistent diagnosis and the older one is diagnosis and the older one is diagnosis the fewer symptoms diagnosis the fewer symptoms that are present.that are present.

Examples Include:Examples Include: Temper outburstsTemper outbursts Aggressive argumentative Aggressive argumentative behaviorbehavior

Fearless Fearless Sleep disturbanceSleep disturbance

Page 11: ADHD Child to Adult Cindy Ruttan DO 2008

Diagnostic concerns…Diagnostic concerns… Can one diagnosis contribute to all Can one diagnosis contribute to all

symptoms reported?symptoms reported? Can you be observing more than one Can you be observing more than one

disorder?disorder? ADHD –diagnosis of exclusion.ADHD –diagnosis of exclusion.

considerconsider: Hyper behavior and Mania/ : Hyper behavior and Mania/ Hypomania Hypomania Decreased focus/inattention Decreased focus/inattention with Depression with Depression

Page 12: ADHD Child to Adult Cindy Ruttan DO 2008

ADHD Co morbiditiesADHD Co morbidities CDCD

Possible reduction in Substance Abuse Disorder Possible reduction in Substance Abuse Disorder ( Drugs and ETOH) if treated early for ADHD ( Drugs and ETOH) if treated early for ADHD with Stimulantswith Stimulants

ODDODD LDLD Anxiety 20-40%Anxiety 20-40%

OCD increase up to 11%^OCD increase up to 11%^ Tourette’s-rare (usually reverse) / TicTourette’s-rare (usually reverse) / Tic

Tic 10-15%^ Tic 10-15%^ Mood Disorder 5-40% depressionMood Disorder 5-40% depression

Bipolar 10-22%^ Bipolar 10-22%^ Poor interpersonal skills/demoralizedPoor interpersonal skills/demoralized

David Krefetz DO MBA FACN, FAPA David Krefetz DO MBA FACN, FAPA ADHD with Comorbidity in Pediatric Populations:ADHD with Comorbidity in Pediatric Populations: Impllications for Eval and Management ^Impllications for Eval and Management ^

Page 13: ADHD Child to Adult Cindy Ruttan DO 2008

DBD (Disruptive BehaviorDBD (Disruptive Behavior Disorder)Disorder)

refers to the refers to the Comorbidity diagnosis of ODD/CDComorbidity diagnosis of ODD/CD

Worry about aggression and Worry about aggression and delinquencydelinquency

Academic underachievementAcademic underachievementIncreased risk for substance abuseIncreased risk for substance abuseIncreased social maladaptationIncreased social maladaptationNote having both DBD and ADHD Note having both DBD and ADHD

makes the ADHD harder to treat.makes the ADHD harder to treat.NO medications FDA approved NO medications FDA approved

for ODD/ CDfor ODD/ CD

Page 14: ADHD Child to Adult Cindy Ruttan DO 2008

Learning DisordersLearning Disorders

InputInput Process of getting info into the brainProcess of getting info into the brain

IntegrationIntegration Organization and understandingOrganization and understanding

MemoryMemory Storage of info to retrieve laterStorage of info to retrieve later

OutputOutput Communicate from brain to others or put Communicate from brain to others or put

into action in the environmentinto action in the environment

ADHD and LD Booklet for Parents by Larry B Silver MDADHD and LD Booklet for Parents by Larry B Silver MD

Page 15: ADHD Child to Adult Cindy Ruttan DO 2008

Input DisabilityInput Disability

Visual PerceptionVisual Perception Auditory PerceptionAuditory Perception Auditory Lag Auditory Lag (Auditory (Auditory Processing )Processing )

ADHD and LD Booklet for Parents by Larry B Silver MDADHD and LD Booklet for Parents by Larry B Silver MD

Page 16: ADHD Child to Adult Cindy Ruttan DO 2008

Integration DisabilityIntegration Disability

SequencingSequencingAbstractionAbstractionOrganizationOrganizationMemoryMemory

ADHD and LD Booklet for Parents by Larry B Silver MDADHD and LD Booklet for Parents by Larry B Silver MD

Page 17: ADHD Child to Adult Cindy Ruttan DO 2008

Output DisabilityOutput Disability

Language Language MotorMotor

GrossGrossFineFineADHD and LD Booklet for Parents by Larry B Silver MDADHD and LD Booklet for Parents by Larry B Silver MD

Page 18: ADHD Child to Adult Cindy Ruttan DO 2008

DiagnosingDiagnosing ADHDADHD NO lab tests, or psychologic tests NO lab tests, or psychologic tests

that definitely diagnose.that definitely diagnose. Recommend Academic Testing to Recommend Academic Testing to

establish level in school and any establish level in school and any LD’s.LD’s.

Obtain Conners Forms or Obtain Conners Forms or Vanderbuilt Scales that help with Vanderbuilt Scales that help with defining criteria –or use the DSM IV defining criteria –or use the DSM IV criteria.criteria.

TOVA or CPT may help with TOVA or CPT may help with identification of ADHD symptoms identification of ADHD symptoms and how well the meds are working.and how well the meds are working.

Page 19: ADHD Child to Adult Cindy Ruttan DO 2008
Page 20: ADHD Child to Adult Cindy Ruttan DO 2008
Page 21: ADHD Child to Adult Cindy Ruttan DO 2008

Early Medical interventionEarly Medical interventionwith Medication has shown:with Medication has shown:

For individuals with ADHD in For individuals with ADHD in childhood to decrease the risk for childhood to decrease the risk for subsequent non-nicotine SUD in subsequent non-nicotine SUD in adol and early adulthood. adol and early adulthood.

? (Worked best for those with the milder ? (Worked best for those with the milder form of ADHD)form of ADHD)

A Literature Review Series Vol 1 No. 3A Literature Review Series Vol 1 No. 3

Page 22: ADHD Child to Adult Cindy Ruttan DO 2008

Children with ADHD at risk for Children with ADHD at risk for ETOH problemsETOH problems ADHD is a risk factor for ETOH ADHD is a risk factor for ETOH

problems –parental behaviors and problems –parental behaviors and environmental stress contribute too.environmental stress contribute too. More likely to drink heavy and to have More likely to drink heavy and to have

enough problems to diagnose ETOH enough problems to diagnose ETOH Abuse or Dependency.Abuse or Dependency.

onset average age 15 onset average age 15 Consider a possible subset of ADHD Consider a possible subset of ADHD

disorder with antisocial behavior patternsdisorder with antisocial behavior patterns ETOH and ADHD seem to run in ETOH and ADHD seem to run in

families which thus seem to be under families which thus seem to be under more “stress” situations.more “stress” situations.

Addiction Science Made Easy 4-8-07Addiction Science Made Easy 4-8-07 WWW.NATTC.orgWWW.NATTC.org

Page 23: ADHD Child to Adult Cindy Ruttan DO 2008

Young Adults –college ageYoung Adults –college age

Problems noted:Problems noted: Harder to adjust to adult life, college life with Harder to adjust to adult life, college life with

poorer social skills and less self esteem.poorer social skills and less self esteem. Lower GPA, less financially, inc. school drop outLower GPA, less financially, inc. school drop out Less methodical, inc. procrastination, less self Less methodical, inc. procrastination, less self

control/self disciplinary behaviors control/self disciplinary behaviors

Symptoms look differentSymptoms look different Impulsive and hyper = mental restlessness or Impulsive and hyper = mental restlessness or

subjective feelings of such.subjective feelings of such.

Page 24: ADHD Child to Adult Cindy Ruttan DO 2008

Adult ADHDAdult ADHD

Nature of disorder is disorganized, Nature of disorder is disorganized, forgetful and poor self regulation forgetful and poor self regulation

Majority can not remember to take Majority can not remember to take their medication if on IR or multi their medication if on IR or multi doses needed.doses needed. InconvenienceInconvenience EmbarrassedEmbarrassed Safety and long term effectsSafety and long term effects Different feeling…Different feeling…

Page 25: ADHD Child to Adult Cindy Ruttan DO 2008

Adult ADHDAdult ADHD

Basic same core symptoms as Basic same core symptoms as with Peds ADHDwith Peds ADHD

Review HX of Ed, job and Review HX of Ed, job and familyfamily

Standard rating Standard rating scales/specific for ADULTS scales/specific for ADULTS

Collateral info coping Collateral info coping /stressors/stressors

Rule out other diagnosisRule out other diagnosis Review options for Review options for

Treatment as they match Treatment as they match patient goalspatient goals Meds/ CBTMeds/ CBT

Page 26: ADHD Child to Adult Cindy Ruttan DO 2008
Page 27: ADHD Child to Adult Cindy Ruttan DO 2008

Adult ADHD who had Adult ADHD who had diagnosis as childdiagnosis as child Many loose full diagnostic Many loose full diagnostic

status( functional remission)10% vs status( functional remission)10% vs Persistent ADHD at15% by 25 yrs Persistent ADHD at15% by 25 yrs old.old.

reality is ADHD had remitted only for reality is ADHD had remitted only for a minority.a minority.

Inattentiveness remains when Inattentiveness remains when inattention and Hyperactivity decline.inattention and Hyperactivity decline.

If one put partial remission + Persistant If one put partial remission + Persistant = 65% have symptoms of ADHD.= 65% have symptoms of ADHD.

Page 28: ADHD Child to Adult Cindy Ruttan DO 2008

Functional ImpairmentFunctional Impairment

Lower Socioeconomic Lower Socioeconomic Relationship impairedRelationship impaired Dec. academic accomplishmentsDec. academic accomplishments Employment issuesEmployment issues Driving record badDriving record bad Dating, vol. work, community Dating, vol. work, community

service, socializing with friends service, socializing with friends /family, culture and educational out /family, culture and educational out of school activities limited. of school activities limited.

Page 29: ADHD Child to Adult Cindy Ruttan DO 2008

Adult ADHD cont-Adult ADHD cont-

Common Common Maladaptive Maladaptive Beliefs:Beliefs:

Self mistrustSelf mistrust FailureFailure InadequateInadequate IncompetentIncompetent InstabilityInstability

Common Common Dysfunctional Dysfunctional Coping Behaviors Coping Behaviors seen: seen:

AvoidanceAvoidance Procrastination Procrastination Pseudo efficiency Pseudo efficiency

low priority tasks low priority tasks first then high first then high priority tasks last.priority tasks last.

Busy without Busy without completion of completion of thingsthings

Page 30: ADHD Child to Adult Cindy Ruttan DO 2008

Co morbidity is “The RULE” Co morbidity is “The RULE” with Adult ADHDwith Adult ADHD

Mood Disorders—Mood Disorders—50-60%50-60%

Depression-Depression-recurrentrecurrent

BADBAD

CyclothymiaCyclothymia

DysthymiaDysthymia

DEP NOSDEP NOS

Anxiety DisordersAnxiety Disorders

40-50%40-50%

GADGAD

Anxiety NOSAnxiety NOS

Page 31: ADHD Child to Adult Cindy Ruttan DO 2008

Co morbidity cont-Co morbidity cont-Adult ADHDAdult ADHDVarious % Various % SUDSUD LDLD IEDIED TouretteTourette Antisocial Personality DisorderAntisocial Personality Disorder Borderline Personality DisorderBorderline Personality Disorder Dependent Personality DisorderDependent Personality Disorder

Page 32: ADHD Child to Adult Cindy Ruttan DO 2008

Behavioral Behavioral InterventionsInterventions

Page 33: ADHD Child to Adult Cindy Ruttan DO 2008

Treatment Options Treatment Options withwith or or withoutwithout medications 1 medications 1 PraisePraise reward positive reward positive

behaviors by : behaviors by : verbalize itverbalize it

Speak individual / publicSpeak individual / public Write it Write it Reward itReward it

Physical Activity -participationPhysical Activity -participation Material - for doing good job in classMaterial - for doing good job in class

Dec / Jan 2008 ADDitude Magazine pg 49Dec / Jan 2008 ADDitude Magazine pg 49

Page 34: ADHD Child to Adult Cindy Ruttan DO 2008

Cont: Treatment Options Cont: Treatment Options with or or withoutwithout Medication 2 Medication 2 Follow up with teachers regarding childs Follow up with teachers regarding childs

Positive and Negative attributesPositive and Negative attributes. Keep . Keep open communication.open communication.

Make sure IEP/504 is being used.Make sure IEP/504 is being used. Address LD issues and grade Address LD issues and grade

appropriate level of work in sinkappropriate level of work in sink Do help at home with homework or Do help at home with homework or

working ahead if possible/ tutorworking ahead if possible/ tutor

Dec / Jan 2008 ADDitude Magazine pg 49Dec / Jan 2008 ADDitude Magazine pg 49

Page 35: ADHD Child to Adult Cindy Ruttan DO 2008

Cont: Treatment Options Cont: Treatment Options with or or withoutwithout Medication 3 Medication 3 Encourage routine healthy food and snacks –due Encourage routine healthy food and snacks –due

to side effects form medicationsto side effects form medications Peanut butter / double up on Breakfast drinkPeanut butter / double up on Breakfast drink

Consider type and delivery style of medications Consider type and delivery style of medications including time frame medications given and duration including time frame medications given and duration of actionof action

Keep structured as possible and avoid chaotic Keep structured as possible and avoid chaotic situations-you as a parent stay calm, cool and situations-you as a parent stay calm, cool and collected.collected.

Give yourself time to accomplish the task/ goal Give yourself time to accomplish the task/ goal desired. Keep a Daytimer/ planner if neededdesired. Keep a Daytimer/ planner if needed

Give an exercise break Give an exercise break

Dec / Jan 2008 ADDitude Dec / Jan 2008 ADDitude Magazine pg 49Magazine pg 49

Page 36: ADHD Child to Adult Cindy Ruttan DO 2008

Cont: Treatment Options Cont: Treatment Options with or or withoutwithout Medication 4 Medication 4 Use verbal and non-verbal cues to Use verbal and non-verbal cues to

remind or stay focusedremind or stay focused Keep good sleep hygiene. Insomnia Keep good sleep hygiene. Insomnia

is common with ADD/ ADHD either a is common with ADD/ ADHD either a part of the disorder itself or part of the disorder itself or exacerbated by medicationsexacerbated by medications

Try to avoid arguments and Try to avoid arguments and confrontations leading to poor self confrontations leading to poor self esteemesteem

Dec / Jan 2008 ADDitude Magazine pg 49Dec / Jan 2008 ADDitude Magazine pg 49

Page 37: ADHD Child to Adult Cindy Ruttan DO 2008

Therapy Goal:Therapy Goal:

Sensitize the patient to and Sensitize the patient to and interrupt dysfunctional behaviorsinterrupt dysfunctional behaviors Coping skillsCoping skills Problem focused Problem focused Adaptive thinkingAdaptive thinking Anger managementAnger management Communication skillsCommunication skills

Page 38: ADHD Child to Adult Cindy Ruttan DO 2008

RX TreatmentsRX Treatments

Page 39: ADHD Child to Adult Cindy Ruttan DO 2008

Medication OptionsMedication Options

19 meds are FDA approved19 meds are FDA approved18 are stimulants18 are stimulants

Use Lowest Dose which addresses Use Lowest Dose which addresses symptoms—as one increases dose if symptoms—as one increases dose if no improvement noted than lowest no improvement noted than lowest dose which provided improvement is dose which provided improvement is the best dose.the best dose.

List symptoms from patients concern List symptoms from patients concern then family and compare… may not then family and compare… may not agree.agree.

Page 40: ADHD Child to Adult Cindy Ruttan DO 2008

Medication DiversionMedication Diversion Transfer of meds from one it is prescribed to Transfer of meds from one it is prescribed to

one whom it is not.one whom it is not. Taking more (quantity)Taking more (quantity) misuse for Euphoric desiremisuse for Euphoric desire Combo with other substancesCombo with other substancesStudy of those Diagnosed with ADHD and its Study of those Diagnosed with ADHD and its

misuse:misuse:22% of adol and young adults in study misused 22% of adol and young adults in study misused

in some capacity.in some capacity.ADHD patients Sold it more than the non ADHD patients Sold it more than the non ADHD group. Those who sold had comorbid ADHD group. Those who sold had comorbid diagnosis of SUD and CD.diagnosis of SUD and CD.

IR prep most often divertedIR prep most often diverted

A Literature Review Series Vol 1 No. 3 Pg 19-21A Literature Review Series Vol 1 No. 3 Pg 19-21

Page 41: ADHD Child to Adult Cindy Ruttan DO 2008

MedicationsMedications

StimulantsStimulants Short Short IntermediateIntermediate Long Long Transdermal Transdermal

Stimulant Pro DrugsStimulant Pro Drugs Non StimulantsNon Stimulants

SNRI SNRI Adrenergic AgentsAdrenergic Agents AntidepressantsAntidepressants Dopaminergic AgentsDopaminergic Agents

Page 42: ADHD Child to Adult Cindy Ruttan DO 2008

Stimulants FDA ApprovedStimulants FDA Approved

Adult FDA Approved is in BLUEAdult FDA Approved is in BLUE Amphetamine Amphetamine

AdderallAdderall DexedrineDexedrine DextrostatDextrostat Adderall XR 2004Adderall XR 2004 Dexedrine SpanulesDexedrine Spanules

Not recommended under age 3 yrsNot recommended under age 3 yrs

Page 43: ADHD Child to Adult Cindy Ruttan DO 2008

Stimulants cont-Stimulants cont-FDA approvedFDA approved

MethylphenidateMethylphenidate RitalinRitalin Methylin chewable, Oral solMethylin chewable, Oral sol Metadate ERMetadate ER FocalinFocalin Focalin XR 2005Focalin XR 2005 Methylin ERMethylin ER Ritalin SRRitalin SR Metadate CDMetadate CD Ritalin LA Ritalin LA ConcertaConcerta

Not recommended for children under age 6Not recommended for children under age 6

Page 44: ADHD Child to Adult Cindy Ruttan DO 2008

MethylphendateTransdermal PatchMethylphendateTransdermal Patch

New Stimulant Delivery New Stimulant Delivery

OptionOption

Page 45: ADHD Child to Adult Cindy Ruttan DO 2008

Transdermal Methylphenidate PatchTransdermal Methylphenidate Patch

Daytrana Daytrana FDA approved ages 6-12FDA approved ages 6-12 10,15, 20 and 30 mg10,15, 20 and 30 mg Recommended one patch dailyRecommended one patch daily Start with the 10 mg patch if no improvement in 1 Start with the 10 mg patch if no improvement in 1

week increase-- cont to adjust dose per 1 week week increase-- cont to adjust dose per 1 week intervals.intervals.

Location hip (rotate area/ sides) may cause irritation Location hip (rotate area/ sides) may cause irritation Delivered over 9 hoursDelivered over 9 hours Possibly effects initial height but minimal to not Possibly effects initial height but minimal to not

significant in adulthoodsignificant in adulthood Much the same side effect profile as oral agentsMuch the same side effect profile as oral agents Remove 2 hours prior to effectsRemove 2 hours prior to effects wearing off.wearing off.

Current Psychiatry Vol 5 No.6 / June 2006Current Psychiatry Vol 5 No.6 / June 2006

Page 46: ADHD Child to Adult Cindy Ruttan DO 2008

Stimulant Pro DrugStimulant Pro Drug

Vyvanse - LisdexamfetamineVyvanse - Lisdexamfetamine FDA approvedFDA approved for for ages 6-12ages 6-12

30, 50, and 70 mg capsules30, 50, and 70 mg capsules

Start with 30 mg/day. If needed titrate up with Start with 30 mg/day. If needed titrate up with 20mg every 3-7 days as tolerated to max of 70 20mg every 3-7 days as tolerated to max of 70 mg/daymg/day

1.1. Effect about 12 hoursEffect about 12 hours2.2. Steady state in 2-3 daysSteady state in 2-3 days3.3. Half life 9.5 hoursHalf life 9.5 hours

Current Psychiatry Vol.6 no.6 June 2007Current Psychiatry Vol.6 no.6 June 2007

Page 47: ADHD Child to Adult Cindy Ruttan DO 2008

Vyvanse – Vyvanse – Lisdexamfetamine cont-2Lisdexamfetamine cont-2Blocks NE and Dopamine reuptake in Presyn Blocks NE and Dopamine reuptake in Presyn

neuronneuronNoted improvement 2 hrs after dosing.Noted improvement 2 hrs after dosing.Large change in corrected QTC intervals--? Large change in corrected QTC intervals--?

Need more info about cardiac riskNeed more info about cardiac risk Possibly Less risk for abuse at Possibly Less risk for abuse at

recommended doses—may be misused at recommended doses—may be misused at higher than therapeutic doses.higher than therapeutic doses.

Current Psychiatry Vol.6 no.6 June 2007Current Psychiatry Vol.6 no.6 June 2007

Page 48: ADHD Child to Adult Cindy Ruttan DO 2008

Vyvanse – Vyvanse – Lisdexamfetamine cont-3Lisdexamfetamine cont-3 Caution in Patients:Caution in Patients:

Co morbid eating Co morbid eating Sleep disorderSleep disorder HTN or cardiovascular illnessHTN or cardiovascular illness

Monitor HR and BPMonitor HR and BP

Do not prescribe to patients taking Do not prescribe to patients taking MAOIMAOI or who or who have taken one in 2 have taken one in 2 weeks of the presentation.weeks of the presentation.

Current Psychiatry Vol.6 no.6 June 2007Current Psychiatry Vol.6 no.6 June 2007

Page 49: ADHD Child to Adult Cindy Ruttan DO 2008

Stimulant: side effectsStimulant: side effects

Review Black Box WarningsReview Black Box Warnings regarding CV risks and Sudden regarding CV risks and Sudden Death.Death.

Encourage Food prior to taking Encourage Food prior to taking MedicationsMedications

Understand possibility of PsychosisUnderstand possibility of Psychosis May make Mania or Tics worseMay make Mania or Tics worse Can write for 90 day RXN as of Dec Can write for 90 day RXN as of Dec

0707

Page 50: ADHD Child to Adult Cindy Ruttan DO 2008

Stimulant Black Box WarningsStimulant Black Box Warnings

Pre-existing Cardiac Pre-existing Cardiac abnormality, abnormality, cardiomyopathy, arrythmias, cardiomyopathy, arrythmias, or other disorders which or other disorders which the use of a the use of a sympathomimetic could be sympathomimetic could be dangerous or increase the dangerous or increase the vulnerability of patients vulnerability of patients liveslives.. Murmurs, syncopy history, HTNMurmurs, syncopy history, HTN

Consult Cardiology to be safe.Consult Cardiology to be safe. Current Psychiatry Vol. 5 No. 10 / Oct 2006Current Psychiatry Vol. 5 No. 10 / Oct 2006

Page 51: ADHD Child to Adult Cindy Ruttan DO 2008

STRATTERA = STRATTERA = Atomoxetine 2002Atomoxetine 2002

FDA approved for: FDA approved for: ChildChildAdolAdoladultadult

Page 52: ADHD Child to Adult Cindy Ruttan DO 2008

SNRISNRI – –AtomoxetineAtomoxetine Non Stimulant --FDA Approved Non Stimulant --FDA Approved Full effect 3-7 weeks peak levels 1-2 hrs or Full effect 3-7 weeks peak levels 1-2 hrs or

3-4 for slow metabolizers3-4 for slow metabolizers Shorter sleep latency , improved sleepShorter sleep latency , improved sleep Increased risk of suicidal ideation in Increased risk of suicidal ideation in

children and adolescents (see precautions)children and adolescents (see precautions) Dose by Body Weight.Dose by Body Weight.

Do not exceedDo not exceed 1.4 mg/kg/day or 100 mg 1.4 mg/kg/day or 100 mg whichever is less.whichever is less. Start low go slow (start Start low go slow (start 0.5mg/kg/day for 10 day then 0.8 for 10 days 0.5mg/kg/day for 10 day then 0.8 for 10 days then 1.2 in a individual or BID dose)then 1.2 in a individual or BID dose)

Over 70 kg start at 40 mg dose and increase Over 70 kg start at 40 mg dose and increase after 10 days to 60 mg for 10 days then to 80mg after 10 days to 60 mg for 10 days then to 80mg after 2-4 weeks consider max dose at 100 mg/ after 2-4 weeks consider max dose at 100 mg/ day. day.

Page 53: ADHD Child to Adult Cindy Ruttan DO 2008

Cont:SNRICont:SNRI - -AtomoxetineAtomoxetine

Safety not established under age 6 yearsSafety not established under age 6 years Lower dose if a slow CYP2D6 metabolizer Lower dose if a slow CYP2D6 metabolizer

or go slower to increase after 4 weeks if on or go slower to increase after 4 weeks if on another drug which also uses/ inhibits 2D6another drug which also uses/ inhibits 2D6

Modify dose by 50-25 % theraputic dose if Modify dose by 50-25 % theraputic dose if hepatic issues hepatic issues

Monitor BP,hepatic dysfunction,CV issues Monitor BP,hepatic dysfunction,CV issues always review the Adv. Effects list.always review the Adv. Effects list.

Monitor BPMonitor BP Adults with more Anxiety, emotional Adults with more Anxiety, emotional

dysregulationdysregulation

Page 54: ADHD Child to Adult Cindy Ruttan DO 2008

Cont:SNRICont:SNRI - -AtomoxetineAtomoxetine

Adults start with 40 mg then in 3 Adults start with 40 mg then in 3 days increase to 80 mg either in days increase to 80 mg either in one AM dose or split dose 40 one AM dose or split dose 40 bid. Max is 100mg.bid. Max is 100mg.

Page 55: ADHD Child to Adult Cindy Ruttan DO 2008

Adrenergic OptionsAdrenergic Options Not FDA approved in children Not FDA approved in children or Adolescentsor Adolescents Clonidine Clonidine

Helps with impulsivity, insomnia associated with Helps with impulsivity, insomnia associated with Stimulant meds, hyperarousal, agitation, and tic Stimulant meds, hyperarousal, agitation, and tic disorderdisorder

Oral and transdermal patchOral and transdermal patch

Side affects:Side affects: Sedation daytime if dosed in daytime.Sedation daytime if dosed in daytime. Withdrawl hypertensive episodesWithdrawl hypertensive episodes 5 reported sudden deaths5 reported sudden deaths when used in when used in

combo with stimulantscombo with stimulants

Page 56: ADHD Child to Adult Cindy Ruttan DO 2008

Adrenergic OptionsAdrenergic Options Not FDA approved in children Not FDA approved in children or Adolescentsor Adolescents GuanfacineGuanfacine

Similar to Clonidine in it’s usesSimilar to Clonidine in it’s uses Less sedation and hypotension than Less sedation and hypotension than

ClonidineClonidine Not recommended or use with caution in Not recommended or use with caution in

patients with renal insufficiencypatients with renal insufficiency Refractory ADHD with Tic issues, may Refractory ADHD with Tic issues, may

help with nightmares associated with help with nightmares associated with PTSDPTSD

Always read Adverse Effects, Always read Adverse Effects, contraindications and Precautions in contraindications and Precautions in the package insertsthe package inserts

Page 57: ADHD Child to Adult Cindy Ruttan DO 2008

AntidepressantsAntidepressants: : Not FDA Not FDA approved in children/adolecents for approved in children/adolecents for ADHD treatment nor Adults for ADHDADHD treatment nor Adults for ADHD Buproprion max 450 mg/ day in Buproprion max 450 mg/ day in

Divided dose unless using 300XL for Divided dose unless using 300XL for Once daily dosing.Once daily dosing. 50 % or adult respond50 % or adult respond HA, Dry mouth, nausea, insomniaHA, Dry mouth, nausea, insomnia

Venlafaxine prelim studies suggest Venlafaxine prelim studies suggest efficacy efficacy

TCA’s (Amitriptyline, desipramine, TCA’s (Amitriptyline, desipramine, imipramine,nortriptyline)imipramine,nortriptyline)

MAOI’s open label suggest improved MAOI’s open label suggest improved concentration in children with ADHDconcentration in children with ADHD

Page 58: ADHD Child to Adult Cindy Ruttan DO 2008

Dopaminergic Agents: Dopaminergic Agents: Not FDA Not FDA approved in Adults or children **approved in Adults or children **

Cholinergic Agents:Cholinergic Agents:Not FDA Not FDA approved in Adults or children *approved in Adults or children *

Modafinil** Modafinil** Donepezil* Donepezil*

Page 59: ADHD Child to Adult Cindy Ruttan DO 2008

Herbal and Natural Products:Herbal and Natural Products:Not FDA approved in Adults or Not FDA approved in Adults or children for ADHDchildren for ADHD Ginko BilobaGinko Biloba Omega 3 Fatty AcidsOmega 3 Fatty Acids Vitamins/MineralsVitamins/Minerals

ZincZincIronIron

Page 60: ADHD Child to Adult Cindy Ruttan DO 2008

Treatment Summary Treatment Summary

RX treatment optimal and better RX treatment optimal and better for core symptoms than for core symptoms than Behavioral treatment alone.Behavioral treatment alone.

Combo of RX and Behavioral Combo of RX and Behavioral was superior to either alone.was superior to either alone.

Page 61: ADHD Child to Adult Cindy Ruttan DO 2008

Can meet someone, fall deeply in love,

marry, fight, hate, and divorce,

all in about 35 minutes or less.

 

 

Page 62: ADHD Child to Adult Cindy Ruttan DO 2008

Clinical Practice GuidelinesClinical Practice Guidelines CPG’s CPG’s www.pediatrics.org/cgi/content/full/105/5/11www.pediatrics.org/cgi/content/full/105/5/11

5858 www.aacap.org/galleries/practiceParametewww.aacap.org/galleries/practiceParamete

rs/New_ADHD_Parameter.pdfrs/New_ADHD_Parameter.pdf

Valid rating scale:Valid rating scale: VanderbuiltVanderbuilt Conners FormsConners Forms www.massgeneral.org/schoolpsychiatry/screeningtoowww.massgeneral.org/schoolpsychiatry/screeningtoo

ls_table.aspls_table.asp www.med.nyu.edu/psych/assets/adhdscreen18.pdfwww.med.nyu.edu/psych/assets/adhdscreen18.pdf

Vol. 6 No. 4 /April 2007Vol. 6 No. 4 /April 2007

Page 63: ADHD Child to Adult Cindy Ruttan DO 2008

ReferencesReferences The Psychiatric Interview 2The Psychiatric Interview 2ndnd Ed. Carlat Ed. Carlat Dec/Jan2008ADDitude MagazineDec/Jan2008ADDitude Magazine Clinical Handbook of Psychotropic Drugs for Clinical Handbook of Psychotropic Drugs for

children and adolescents 2children and adolescents 2ndnd Ed. Kalyna Ed. Kalyna Bezchlibnyk-Butler and Adil Virani Bezchlibnyk-Butler and Adil Virani

Current Psychiatry Current Psychiatry Vol.5 No. 2 / Feb.2006 Vol.5 No. 2 / Feb.2006

Atomoxetine package insertAtomoxetine package insert New Perspectives on Adult ADHD New Perspectives on Adult ADHD

College Years CME Part 5 of 6College Years CME Part 5 of 6 ADHD : A Disorder with Life time Impact CME part 3 of ADHD : A Disorder with Life time Impact CME part 3 of

66 Advances in ADULT ADHD CME Part 7 of 8Advances in ADULT ADHD CME Part 7 of 8

ADHD Drug Therapy: Long and short of it.ADHD Drug Therapy: Long and short of it.

Page 64: ADHD Child to Adult Cindy Ruttan DO 2008

ReferencesReferences Primary Psychiatry Primary Psychiatry

July 2004: Vol.11 No.7July 2004: Vol.11 No.7 NeuroPsychiatry Reviews NeuroPsychiatry Reviews

Jan 08 Vol.9 No.1 pg.21Jan 08 Vol.9 No.1 pg.21 Psychiatric News Psychiatric News

Feb.1, 08 Vol 43 No.3 pg.23Feb.1, 08 Vol 43 No.3 pg.23