ADHD WORKSHOP ADHD WORKSHOP FORFORPAEDIATRICIANSPAEDIATRICIANS

UCT Paediatric Refresher UCT Paediatric Refresher CourseCourse

Feb 2010Feb 2010

The role of the The role of the Paediatrician in the Paediatrician in the treatment of ADHDtreatment of ADHD

Diagnosis and managementDiagnosis and management Increase in presentationIncrease in presentation More presentations to Paediatricians and More presentations to Paediatricians and

reluctance to visit a Psychiatristreluctance to visit a Psychiatrist Families need from PaediatricianFamilies need from Paediatrician Awareness of differential diagnosisAwareness of differential diagnosis Awareness of co-morbidityAwareness of co-morbidity Medication cornerstone of treatment but holistic Medication cornerstone of treatment but holistic

approach very NBapproach very NB Paediatrician may be first professional to notice Paediatrician may be first professional to notice

ADHDADHD

General concepts of General concepts of ADHDADHD Aetiological and symptomatic Aetiological and symptomatic

understandingunderstanding

Predominantly a neurobiological Predominantly a neurobiological conditioncondition

Strong family historyStrong family history Constellation of symptoms (vs. signs)Constellation of symptoms (vs. signs) Core symptoms: InattentionCore symptoms: Inattention

Hyperactivity/ImpulsivityHyperactivity/Impulsivity DSM IV criteria DSM IV criteria

criteriacriteria

INATTENTIONINATTENTION Failure to give close attention to detailFailure to give close attention to detail Difficulty sustaining attentionDifficulty sustaining attention Not listening when spoken to directlyNot listening when spoken to directly Inability to finish work / follow through Inability to finish work / follow through

instructionsinstructions Difficulty organizing tasks or activitiesDifficulty organizing tasks or activities Avoidance of tasks requiring sustained Avoidance of tasks requiring sustained

mental effortmental effort

Often looses things required for tasksOften looses things required for tasks Easily distractedEasily distracted Forgetful in daily activitiesForgetful in daily activities 6 symptoms required6 symptoms required HYPERACTIVITYHYPERACTIVITY FidgetyFidgety Difficulty remaining in seatDifficulty remaining in seat Excessive running about / subjective feeling of Excessive running about / subjective feeling of

restlessnessrestlessness Difficulty engaging in leisure activity quietlyDifficulty engaging in leisure activity quietly On the go / “driven by motor”On the go / “driven by motor” Excessive talkingExcessive talking

IMPULSIVITYIMPULSIVITY Blurting out of answersBlurting out of answers Difficulty waiting turnDifficulty waiting turn Often interrupts or intrudes on othersOften interrupts or intrudes on others 6 criteria required6 criteria required

ALSOALSO Symptoms present before age 7 Symptoms present before age 7

yearsyears Impairment in 2 or more settingsImpairment in 2 or more settings Impaired functioningImpaired functioning Symptoms not due to other Symptoms not due to other

causescauses

Spectrum of presentation Spectrum of presentation i.e.. Below threshold presentation vs. i.e.. Below threshold presentation vs. mild/moderate presentation vs. mild/moderate presentation vs. severe and complicated presentation severe and complicated presentation with several comorbid conditions with several comorbid conditions

Up to 50% of children have co Up to 50% of children have co morbid disorder(s) morbid disorder(s)

Impairment in social, family and Impairment in social, family and academic functioningacademic functioning

Occurrence in at least 2 settingsOccurrence in at least 2 settings Onset during childhoodOnset during childhood Longitudinal course - 2/3 of Longitudinal course - 2/3 of

patients progress into adulthood patients progress into adulthood

Why are more children presenting now?Why are more children presenting now?

““Evolutionary” concept of ADHDEvolutionary” concept of ADHD

How/why do most patients/families How/why do most patients/families present?present?

Disruption (in class) probably most Disruption (in class) probably most common reason for referral common reason for referral

Has modern society Has modern society created a disorder from a created a disorder from a previous strength?previous strength? Genetic and adaptive factors in ADHDGenetic and adaptive factors in ADHD Information overloadInformation overload Stimulation overloadStimulation overload Academic overloadAcademic overload Outsourcing of careOutsourcing of care Is it normal for a child to sit still at a Is it normal for a child to sit still at a

desk for 6 – 8 hoursdesk for 6 – 8 hours Societal issues vs mental health issuesSocietal issues vs mental health issues

Why NB to treatWhy NB to treat

Academic potentialAcademic potential DisruptionDisruption Self esteemSelf esteem Impaired functioning (academic, Impaired functioning (academic,

social, family )social, family ) co morbidityco morbidity

Evaluation of/Clinical Evaluation of/Clinical approach to the child approach to the child presenting with ADHD presenting with ADHD May depend on referral source e.g.. May depend on referral source e.g..

Psychologist, school, parents etcPsychologist, school, parents etc

N.B. to take ones time, i.e. extended N.B. to take ones time, i.e. extended consult, 2-3 consultationsconsult, 2-3 consultations

Differential diagnosis and co morbidity Differential diagnosis and co morbidity always need to be born in mindalways need to be born in mind

Interview with parents (may need Interview with parents (may need to start off without the child)to start off without the child)

Child interviewChild interview Family observationFamily observation Physical information/evaluation of Physical information/evaluation of

the childthe child Additional Additional

information/investigationinformation/investigation

Interview with parentsInterview with parents

May initially be necessary to May initially be necessary to exclude the childexclude the child

Presenting complaintPresenting complaint History of presenting complaintHistory of presenting complaint DSM IV checklistDSM IV checklist Context of symptomsContext of symptoms Resulting impairments Resulting impairments

Differential diagnosis i.e. may the Differential diagnosis i.e. may the child’s symptoms be due to child’s symptoms be due to another cause other than ADHDanother cause other than ADHD

Co morbidity i.e. are there Co morbidity i.e. are there additional emotional symptoms additional emotional symptoms that the child is displaying e.g.. that the child is displaying e.g.. Mood, anxiety, conduct, defiance, Mood, anxiety, conduct, defiance, intellectual impairment etc.intellectual impairment etc.

Past psychiatric history including Past psychiatric history including ADHD and treatment, past ADHD and treatment, past alternative treatmentsalternative treatments

Developmental historyDevelopmental history Areas of strengthAreas of strength Medical history including Medical history including

medicationsmedications

Family historyFamily history

History of ADHD or co morbid History of ADHD or co morbid disorderdisorder

Learning difficultyLearning difficulty Family coping style, level of Family coping style, level of

organisation and resourcesorganisation and resources Family stressorsFamily stressors Signs of abuse and neglect Signs of abuse and neglect

(especially in younger children)(especially in younger children)

Child InterviewChild Interview Note symptoms of ADHD (may Note symptoms of ADHD (may

however be absent during one on however be absent during one on one consultation)one consultation)

Note and explore:Note and explore: DefianceDefiance AggressionAggression AnxietyAnxiety Obsessions and compulsionsObsessions and compulsions

Form, content and logic of Form, content and logic of thinking and perceptionthinking and perception

Fine and gross motor coordinationFine and gross motor coordination Tics and movement disordersTics and movement disorders Speech and language abilitySpeech and language ability Clinical estimate of intellect Clinical estimate of intellect

Family observationFamily observation

Patients behaviour with siblings Patients behaviour with siblings and parentsand parents

Parental responses to child’s Parental responses to child’s behaviourbehaviour

Parental level of agreement Parental level of agreement around child rearing principles around child rearing principles and disciplineand discipline

Physical evaluationPhysical evaluation

Past medical history and medicationPast medical history and medication Medical record over past 12 monthsMedical record over past 12 months Stability of any illnesses e.g. asthma, Stability of any illnesses e.g. asthma,

allergies etc (may tip the balance)allergies etc (may tip the balance) Visual acuityVisual acuity HearingHearing Height, weight and growth chartHeight, weight and growth chart Other evaluation as indicated e.g. Other evaluation as indicated e.g.

neurological, cardiology, developmental neurological, cardiology, developmental assessmentassessment

Additional Additional information/investigationinformation/investigationss

Forms/rating scales completed by Forms/rating scales completed by parents, teachers and significant parents, teachers and significant othersothers

Conner’s forms: basic and extended, Conner’s forms: basic and extended, also important to complete once also important to complete once patient being treatedpatient being treated

School reports (especially the School reports (especially the comments) comments)

Collateral information from teacher Collateral information from teacher and others (aftercare, other carers)and others (aftercare, other carers)

Depending on presentation child may Depending on presentation child may need:need:

Psychometric assessmentPsychometric assessment Speech and language assessmentSpeech and language assessment OT assessmentOT assessment No “special tests” availableNo “special tests” available

Differential and co morbid scanDifferential and co morbid scan

Diagnostic formulationDiagnostic formulation

Treatment planTreatment plan

The younger and older The younger and older childchild Young child: rule out neglect, Young child: rule out neglect,

abuse and other environmental abuse and other environmental factors, mother/parent: child factors, mother/parent: child relationship difficulties may be relationship difficulties may be important contributorimportant contributor

Older child: NB. To make patient Older child: NB. To make patient an active participant in treatment an active participant in treatment

Treatment/Treatment/InterventionIntervention Non pharmacologicalNon pharmacological Pharmacological (cornerstone of Pharmacological (cornerstone of

treatment)treatment)

Non pharmacological Non pharmacological interventionsinterventions Psycho education: parents, child, Psycho education: parents, child,

others others Collaboration with/ interventions at Collaboration with/ interventions at

schoolschool Additional school/ remedial resourcesAdditional school/ remedial resources Support group for parentsSupport group for parents Books and other materialsBooks and other materials Behavioural interventionsBehavioural interventions

Behavioural Behavioural interventionsinterventions Should be part of overall interventionShould be part of overall intervention May be used on own if symptoms May be used on own if symptoms

mild or parents refusing medsmild or parents refusing meds Attend to child’s misbehaviours and Attend to child’s misbehaviours and

complaints (target symptoms)complaints (target symptoms) Token systems (target symptoms)Token systems (target symptoms) Time outTime out Manage non compliant behaviour in Manage non compliant behaviour in

public places PTOpublic places PTO

Daily school report and other Daily school report and other school interventionsschool interventions

Anticipate future misconductAnticipate future misconduct Structure, routine, boundaries, Structure, routine, boundaries,

predictabilitypredictability *** may all be impossible if family *** may all be impossible if family

stressors or if parent(s) have stressors or if parent(s) have ADHD ADHD

Play therapy, CBT and social skills Play therapy, CBT and social skills training not helpful in children who training not helpful in children who only have ADHD/ADDonly have ADHD/ADD

May be useful for co morbid disordersMay be useful for co morbid disorders No empirical evidence for dietary No empirical evidence for dietary

intervention unless proven food intervention unless proven food intolerance intolerance

? Food colorants in the very young? Food colorants in the very young

Pharmacological Pharmacological interventionsinterventions Methylphenidate: Ritalin IRMethylphenidate: Ritalin IR Ritalin LARitalin LA ConcertaConcerta Atomoxetine: StratteraAtomoxetine: Strattera Other: ImipramineOther: Imipramine Clonidine Clonidine

Side effects and their Side effects and their management:Methylphenmanagement:Methylphenidateidate Loss of appetite (daily quantity N.B.)Loss of appetite (daily quantity N.B.) Weight loss (monitor)Weight loss (monitor) Headache, abdominal painHeadache, abdominal pain Rebound phenomenaRebound phenomena AnxietyAnxiety TicsTics DepressionDepression Affective blunting/ emotional labilityAffective blunting/ emotional lability insomniainsomnia

Management of stimulant Management of stimulant S/ES/E loaloa loss of wtloss of wt early insomniaearly insomnia blunted affectblunted affect tictic stereotypic movementstereotypic movement growth delaygrowth delay

• if symptoms severe -- change if symptoms severe -- change to 2nd line medsto 2nd line meds

l o al o a decrease dosagedecrease dosage increase increase

breakfast + breakfast + suppersupper

if early - dev of if early - dev of tolerancetolerance

monitor wt and monitor wt and htht

loss of wtloss of wt decrease dosedecrease dose increase caloric increase caloric

intake (breakfast intake (breakfast and supper)and supper)

no meds over w/e no meds over w/e and holidaysand holidays

monitor wt, monitor wt, growth curvegrowth curve

hope for tolerancehope for tolerance

early insomniaearly insomnia if IR - no meds after if IR - no meds after 3pm3pm

if LA - lower dosage,if LA - lower dosage,give dose give dose earlier, give earlier, give before before breakfast for breakfast for faster absorptionfaster absorption

ensure bedtime routine ensure bedtime routine eg readingeg reading

Clonidine, Clonidine, anntihisamine,melatonianntihisamine,melatoninn

blunted affectblunted affect decrease dosagedecrease dosage

change change

preparationpreparation

tictic discontinue, if tic discontinue, if tic

disappears restartdisappears restart

if tic recurs - if tic recurs -

change medschange meds

stereotypic movement stereotypic movement

decrease dosagedecrease dosage growth delay growth delay

decrease dosagedecrease dosage

drug holidaysdrug holidays

bone age monitoring bone age monitoring on radiograph on radiograph

AtomoxetineAtomoxetine

Gastrointestinal disturbancesGastrointestinal disturbances SedationSedation Decreased appetiteDecreased appetite Hepatic disorderHepatic disorder Black box warning: suicidalityBlack box warning: suicidality ““feeling ill” but unable to verbalizefeeling ill” but unable to verbalize Severe acting out behaviour Severe acting out behaviour

N.B. to discuss side effects before N.B. to discuss side effects before commencing treatmentcommencing treatment

Monitor for side effectsMonitor for side effects

Use of different methylphenidate Use of different methylphenidate preparations i.e. which one to usepreparations i.e. which one to use

Advantages and disadvantageAdvantages and disadvantage

Ritalin vs. StratteraRitalin vs. Strattera

Ritalin generally considered 1Ritalin generally considered 1stst lineline

Consider Strattera if: tics, anxiety, Consider Strattera if: tics, anxiety, Ritalin intolerance, patient Ritalin intolerance, patient preferencepreference

Introducing medicationIntroducing medication

DosageDosage Start over weekend (parents feel in control)Start over weekend (parents feel in control) Warn re side effectsWarn re side effects Ritalin : fast onsetRitalin : fast onset Strattera : 4-6 weeks onset (may start in Strattera : 4-6 weeks onset (may start in

holidays)holidays) Drug holidays ; depends on side effects and Drug holidays ; depends on side effects and

level of functioning off medslevel of functioning off meds Follow up regularly including Connors form Follow up regularly including Connors form

and collateral (see later)and collateral (see later)

A 9 year old girl is on Concerta 36mg A 9 year old girl is on Concerta 36mg

daily. Reports from school indicate that daily. Reports from school indicate that

her concentration remains poor until 1st her concentration remains poor until 1st

break. What would your approach be?break. What would your approach be?

Establish at what time meds are Establish at what time meds are

takentaken

Consider adding 5 - 10mg Ritalin Consider adding 5 - 10mg Ritalin

manemane

An 8 year old girl refuses to take An 8 year old girl refuses to take

Ritalin LA 20mg as she feels she Ritalin LA 20mg as she feels she

cannot swallow it. What would cannot swallow it. What would

you advise?you advise?

An 8 year old boy commenced on An 8 year old boy commenced on Strattera complains of persistent Strattera complains of persistent midday nausea. How would you midday nausea. How would you manage him?manage him?

A single mother presents with her A single mother presents with her four year old son who presents four year old son who presents with symptoms of ADHD. What with symptoms of ADHD. What would your approach to would your approach to management be?management be?

An 11 year old boy with ADHD An 11 year old boy with ADHD and co morbid oppositional and co morbid oppositional disorder stops responding to disorder stops responding to Ritalin LA 20 mg. you increase the Ritalin LA 20 mg. you increase the dosage to 30mg without much dosage to 30mg without much success. How would you approach success. How would you approach this presentationthis presentation

A matriculant presents to you A matriculant presents to you whom you had last seen 4 years whom you had last seen 4 years ago and treated for ADD. He ago and treated for ADD. He decided to stop meds then but decided to stop meds then but now realises he requires them to now realises he requires them to get a decent matric result. How get a decent matric result. How would you approach this would you approach this problem?problem?

Role play : the difficult Role play : the difficult parentsparents

Meds around for over 30 years- no major lawsuits Meds around for over 30 years- no major lawsuits in USAin USA

““drug” dependency issues – the opposite is true, drug” dependency issues – the opposite is true, never come across a child addicted to Ritalin, never come across a child addicted to Ritalin, drug dealers don’t stock Ritalin…Why notdrug dealers don’t stock Ritalin…Why not

Self esteem issues and marginalisationSelf esteem issues and marginalisation Co morbidityCo morbidity Sitting on the other sideSitting on the other side Why withhold something that works e.g. other Why withhold something that works e.g. other

meds (asthma), spectaclesmeds (asthma), spectacles Consideration of trial of medsConsideration of trial of meds In and out of system….like coffeeIn and out of system….like coffee If side effects… at least you can say you triedIf side effects… at least you can say you tried

Empirical evidence of other Empirical evidence of other interventions lacking, i.e. diet, interventions lacking, i.e. diet, multivitamin loading, specialized multivitamin loading, specialized programmes etcprogrammes etc

If there were a proven intervention If there were a proven intervention programme say over 10-15 sessions I programme say over 10-15 sessions I would certainly administer it. It would be would certainly administer it. It would be far more remunerative for mefar more remunerative for me

If you know of a programme show me If you know of a programme show me the evidencethe evidence

Internet myths--- you can find anything Internet myths--- you can find anything on the internet on the internet

Patient follow upPatient follow up

What would your follow up What would your follow up strategy and protocol be for a strategy and protocol be for a patient that you have patient that you have commenced on medication?commenced on medication?

What specific features would you What specific features would you be looking out for?be looking out for?

Frequency of follow up (scripts may act Frequency of follow up (scripts may act as a good gatekeeper)as a good gatekeeper)

Weight, height, pulse and blood pressureWeight, height, pulse and blood pressure Co morbidity check, other disorders may Co morbidity check, other disorders may

creep in over timecreep in over time Assess level of functioning in all spheresAssess level of functioning in all spheres Repeat Connor’s formRepeat Connor’s form Side effectsSide effects DosageDosage When to discontinue? When to discontinue?

Differential diagnosis of Differential diagnosis of ADHD/ADD and co ADHD/ADD and co morbiditymorbidity ADD may often go undetected until ADD may often go undetected until

later. Why?later. Why? Symptoms of ADHD may often Symptoms of ADHD may often

mimic other psychiatric conditionsmimic other psychiatric conditions In addition about 50% of individuals In addition about 50% of individuals

with ADHD meet criteria for one or with ADHD meet criteria for one or more other psychiatric disorder(s)more other psychiatric disorder(s)

The list is long and the treatment The list is long and the treatment may be complexmay be complex

Differential diagnosis Differential diagnosis and Co morbid and Co morbid conditionsconditions Oppositional Defiant DisorderOppositional Defiant Disorder Anxiety Disorders (incl OCD)Anxiety Disorders (incl OCD) Mood Disorders (incl BMD)Mood Disorders (incl BMD) Conduct DisorderConduct Disorder Learning DisorderLearning Disorder Tourette’s Disorder, Motor Tic Tourette’s Disorder, Motor Tic

DisorderDisorder Substance Abuse DisorderSubstance Abuse Disorder

Pervasive Developmental DisorderPervasive Developmental Disorder Sleep Difficulties/DisordersSleep Difficulties/Disorders Accidental InjuriesAccidental Injuries ““Personality Difficulties”, Cluster B traitsPersonality Difficulties”, Cluster B traits Family dysfunctionFamily dysfunction Medical illnesses/ medicationMedical illnesses/ medication

Actively exclude co morbidityActively exclude co morbidity Consider when ADHD “refractory”Consider when ADHD “refractory”

, ,

Joseph Biederman and Stephen Faraone 1996

Differential diagnosisDifferential diagnosis

How would you differentiate a child suffering How would you differentiate a child suffering from ADHD/ADD from the following from ADHD/ADD from the following condition(s):Note that these patients may be condition(s):Note that these patients may be referred to you with a request to treat their referred to you with a request to treat their “ADHD/ADD”“ADHD/ADD”

Anxiety disorder( all types)Anxiety disorder( all types) DepressionDepression Bipolar mood disorderBipolar mood disorder Learning disorderLearning disorder Oppositional defiant disorderOppositional defiant disorder Substance use disorderSubstance use disorder Pervasive developmental disorderPervasive developmental disorder

Similarities in presentationSimilarities in presentation vsvs Differences in presentationDifferences in presentation

See flip chartSee flip chart

Co morbidity and Co morbidity and ADHD/ADDADHD/ADD More complex than establishing whether More complex than establishing whether

another diagnosis/disorder may be another diagnosis/disorder may be responsible for an “ADHD/ADD” responsible for an “ADHD/ADD” presentation is when one or more presentation is when one or more disorders are indeed present in addition to disorders are indeed present in addition to ADHD/ADDADHD/ADD

Furthermore when these disorders present Furthermore when these disorders present during treatment of ADHD we need to ask during treatment of ADHD we need to ask ourselves whether these symptoms could ourselves whether these symptoms could be as a result of medicationbe as a result of medication

If co morbid condition(s) is mild, If co morbid condition(s) is mild, treatment of ADHD may significantly treatment of ADHD may significantly improve co morbid presentationimprove co morbid presentation

Caution in :Caution in : Anxiety disorders and stimulants Anxiety disorders and stimulants

(academic performance anxiety may (academic performance anxiety may however be improved)however be improved)

Tourrette’s disorderTourrette’s disorder Bipolar mood disorderBipolar mood disorder

Psychological intervention often Psychological intervention often necessary when co morbid necessary when co morbid conditions presentconditions present

Polypharmacy may be Polypharmacy may be unavoidableunavoidable

Second opinions often usefulSecond opinions often useful

How would you treat a child with ADHD How would you treat a child with ADHD and the following comorbidities given the and the following comorbidities given the fact that the child/family is receiving fact that the child/family is receiving psychological intervention?psychological intervention?

Tourette’s syndromeTourette’s syndrome PDDPDD BMDBMD Substance abuseSubstance abuse Anxiety disorderAnxiety disorder Depressive disorderDepressive disorder

Tourette’s SyndromeTourette’s Syndrome

clonidineclonidine

atomoxetineatomoxetine

stimulants (not as problematic as stimulants (not as problematic as

initially thought)initially thought)

Pervasive Pervasive Development DisorderDevelopment Disorder

meds not as effective 50% vs meds not as effective 50% vs

70%70%

S/E less well toleratedS/E less well tolerated

can be used but monitorcan be used but monitor

? other agents eg Risperidone? other agents eg Risperidone

B M DB M D

OK to use once stable on mood stabilizerOK to use once stable on mood stabilizer

Substance abuseSubstance abuse

avoid stimulants (however)avoid stimulants (however)

NB preventative roleNB preventative role

Anxiety DisorderAnxiety Disorder

Second line agentsSecond line agents

add SSRIadd SSRI

Depressive disorderDepressive disorder

Consider adding a SSRI Consider adding a SSRI (Fluoxetine)(Fluoxetine)

Imipramine of limited valueImipramine of limited value

Challenging cases over Challenging cases over timetime Imaad, 5 yrs old at end 2007Imaad, 5 yrs old at end 2007 Met parents at ADHD Support GroupMet parents at ADHD Support Group Recently diagnosed with ADHD and had Recently diagnosed with ADHD and had

been commenced on Ritalin 5mg manebeen commenced on Ritalin 5mg mane Now presents with mood swings and Now presents with mood swings and

irritability in afternoonsirritability in afternoons Changed to Concerta 18mg with good effectChanged to Concerta 18mg with good effect Mid 2009 – Psychometric assessment Mid 2009 – Psychometric assessment

reveals some learning difficulties and reveals some learning difficulties and significant ADHD “break through” significant ADHD “break through” symptoms symptoms

Increased dose to 36mg, initially symptoms Increased dose to 36mg, initially symptoms controlledcontrolled

Oct 2009 emergence of vocal tic (parents Oct 2009 emergence of vocal tic (parents concerned +++)concerned +++)

changed to Atomoxetine, Clonidine and changed to Atomoxetine, Clonidine and Risperidone (monotherapy)….. Mild Risperidone (monotherapy)….. Mild reduction of tics but ADHD out of controlreduction of tics but ADHD out of control

Recommenced on Concerta 18mg in Jan Recommenced on Concerta 18mg in Jan 2010, ADHD symptoms controlled, still 2010, ADHD symptoms controlled, still minor vocal ticsminor vocal tics

Lara, grade 1, 2009, Referred with Lara, grade 1, 2009, Referred with diagnosis of ADHD/anxiety…diagnosis of ADHD/anxiety…Aggression on Strattera, mood swings Aggression on Strattera, mood swings on Ritalin, dysinhibited on Fluoxetineon Ritalin, dysinhibited on Fluoxetine

Found to have additional ODD when Found to have additional ODD when seenseen

Predominant symptom ADHDPredominant symptom ADHD Commenced on Concerta 18mgCommenced on Concerta 18mg Developed severe insomnia Developed severe insomnia

Commenced on Risperidone 0,25- Commenced on Risperidone 0,25- 0.5 mg nocte, Concerta stopped0.5 mg nocte, Concerta stopped

ManageableManageable 2010- severe anxiety , not coping 2010- severe anxiety , not coping

at school, psychometric assessment at school, psychometric assessment – discrepencies, weight gain– discrepencies, weight gain

Commenced on 12.5mg Sertraline Commenced on 12.5mg Sertraline recently….. Awaiting responserecently….. Awaiting response

Tristan, aged 8, 2009, ADHD, tics and Tristan, aged 8, 2009, ADHD, tics and temper outbursts. Started on Strattera….temper outbursts. Started on Strattera….

Major “meltdown” requiring hospitalisationMajor “meltdown” requiring hospitalisation Sensitive and hyperreactiveSensitive and hyperreactive Co morbid ODD, anxiety and ? DepressionCo morbid ODD, anxiety and ? Depression Strattera stoppedStrattera stopped Commenced on Risperidone 0,5mg and Commenced on Risperidone 0,5mg and

Fluoxetine 10 mgFluoxetine 10 mg

Reasonable responseReasonable response Concentration difficulties at school Sept2009Concentration difficulties at school Sept2009 Addition of Concerta 18mgAddition of Concerta 18mg Good responseGood response RSA karate champ end 2009RSA karate champ end 2009 Mini “meltdown” beginning school year 2010Mini “meltdown” beginning school year 2010 Parental tensionParental tension Couple counsellingCouple counselling Keeping fingers crossd…… Keeping fingers crossd……

Recent referralRecent referral Learning disorder and ADHDLearning disorder and ADHD

PTOPTO

Comment of the year 2009Comment of the year 2009

A 17 year old boy diagnosed with A 17 year old boy diagnosed with ADHD in Grade 11 and commenced ADHD in Grade 11 and commenced on Methylphenidate:on Methylphenidate:

Marks initially improved by 20%Marks initially improved by 20% ““For the first time in my life I For the first time in my life I

realized that I am not STUPID!”realized that I am not STUPID!”