HISTORY OF ATTENTION DEFICIT DISORDER 1900s Still (England) Deficits in Inhibitory Volition, Moral Control, Sustained Attention. Compared to children of same age. Not related to upbringing, probably hereditary vs brain injury, males more than females 3:1. Many of these childrens had tics (70 % of kids w/ TS, tics have ADHD). 1917 Encephalitis epidemic, North America Researchers studied many survivors. Significant behavioral/cognitive deficits. Some of these kids demonstrated deficits in attention, impulse control and where hyperactive. 1930 - 1960s Minimal Brain Dysfunction Many reports of behavioral/cognitive deficits in children with brain injury due to birth trauma, neurotoxins (lead), head injury, etc. Some of these kids where ADHD, but many more with more serious neurological problems. Nevertheless : Kids with distractibility/hyperactivity/impulsivity must be brain damaged in some way. 1950s Hyperkinesis Hyperkinetic Impulse Disorder Still thought of as a type of brain damage syndrome. 1960s Hyperactive Child Syndrome Emphasis on activity Not necessarily a result of brain injury. Earned itself a place in the DSM II : Hyperkinetic Reaction of Childhood Associated with other neurobehavioral disorders, MR, etc. 1970s Attention Deficits Further understood that brain injury/damage not major cause Many studies that targeted attention as a primary problem/cause 1980s Further work on attention/impulsivity issues DSM III and IIIR ADDH then ADHD. Recognized attention deficit with and without hyperactivity 1990s Behavioral Disinhibition and Deficient Rule Governed Behavior. Deficit in attention may not adequately explain ADHD children's response to external stimuli. However, if behavioral dishinibition is thought of as the primary problem, this may adequately explain distractibility and impulsivity. Deficient Rule Governed Behavior. Consequences to behavior, rewards and/or punishment, are not regarded as important by the child with ADHD. Biological? Current Conceptualization Russel Barkley : ADHD may be "a primary deficit in behavioral or response inhibition, the ability to delay responses, or the tolerance for delay intervals within tasks." Based on Bronowski's theory of language and cognitive development. - Separation of Affect - Prolongation - Internalization - Reconstitution An Important Alternative Perception. Hunter Concept ADHD Diagnosis There is no one "test" for ADHD Many conditions can impair attention Evaluation must be multidisciplinary: Medical Comprehensive History Taking Prenatal/Perinatal/Postnatal Medical History Developmental Family DSM IV Criteria for ADHD (and other NBDs?) Complete Physical Neurologic Evaluation Growth Additional Testing Vision and Hearing (Complete Audiological if ? CAP) Blood Work - Thyroid EEG? Cardiac Evaluation, EKG, etc. to evaluate potential med problems Educational/Academic Academic Performance Questionnaires Multidisciplinary Evaluation IQ and Achievement Testing Psychological/Social/Family Psychological Evaluation Family Issues Differential Diagnosis Other emotional/behavioral problems Other Comprehensive Developmental Evaluation ADHD Important Issues Academic Greater liklihood of grade retention, poor academic achievement and dropping out. Often find themselves in trouble, disruptive. Social Making and keeping friends is difficult. Frequently unable to communicate effectively with peers. Often unable to participate in organized activities, ie sports, etc. "Different" Family Takes greater share of attention, resources, etc. within the family ADHD issues can be devisive Self / Self Esteem. Problems in the above arenas can have profound effects on a child's sense of self worth and self esteem. Depression and other emotional problems. ADHD Treatment Issues Treatment must be MultiModal! Psycho-Educational Counseling Medication Behavior Management School Based Intervention Family Therapy Social Competence Training ADHD MEDICATIONS Medications Stimulants Ritalin (methylphenidate) Cylert (pemoline) Dexadrine (d-amphetamine) Catpress (clonidine) Tricyclic Antidepressants (TCAs) Tofranil (imipramine) Norpramine (desipramine) Selective Serotonin Reuptake Inhibitors Prozac (fluoxetine) Paxil (paroxetine) Zoloft (sertraline) Others Wellbutrin (buproprion) Buspar (buspirone) ?????? Stimulants General Comments Most used type of medication in pediatric psychopharmacology Benefits of stimulant therapy can extend into adulthood. 75% of ADHD children will show improvement in some or all of the following areas: Motor behavior Cognitive effects Motivation Academic achievement Interpersonal skills No set dosages Medication trials Questionnaires Feedback from school, other outside activities Observation at home during weekends, holidays, etc. Drug holidays Highly individual Should be flexible Side effects Loss of appetite Insomnia Irritability Abdominal pain Behavioral rebound Tics Depression Tachycardia Liver abnormalities : Cylert (pemoline) only. Suspected and/or unsubstantiated side effects Increased use of recreational drugs - NO! Reduced seizure thresholds - Not proven. Growth retardation - More an indirect side effect as realized by anorexia (?) Toxicity "Spaced Out" "Zombie" Irritable, Emotionally Labile Ritalin (methylphenidate) Schedule II drug Shortage in 1993 because of tight regulation and bureaucratic foul-up. Cannot phone in Rx, No refills Available in regular and slow release Available Dosages : Ritalin : 5, 10, 20 milligrams Ritalin SR : 20 milligrams Generic methylphenidate Less expensive ?? As effective/predictable ?? Usually the first drug tried for ADHD Most effective Well tolerated Easily titrated Works immediately Short half life (3-5 hours) Often dosed 3-4 times a day Flexibility of dosing Dexedrine (d-amphetamine) Similar to other stimulants Schedule II Available dosages Dexedrine tablets : 5, 10 milligrams (10 mg generic only) Dexedrine elixer : 5 mg/5ml (generic) Dexedrine spansules : 5, 10, 15 milligrams (brand name only) FDA approved down to 3 y.o. Longer half life (4-6 hours) May still need multiple daily doses Cylert (pemoline) Similar to other stimulants Schedule IV Refills allowed May phone in Rx Available dosages Cylert tablets : 18.75, 37.5, 75 milligrams Cylert chewables : 37.5 milligrams Longer half life (8+hours) Once a day dose (reduced stigma) Takes longer to achieve full benefit Not as flexible as other stimulants Liver toxicity in approx 1% of patients Usually reversible Needs routine blood work Catapress (clonidine) Antihypertensive, also used in alcohol, drug and nicotine withdrawal. Has been used to reduce tics in Tourette's and more recently to control hyperarousal and aggression in manic patients Recently has gained broad support in use for ADHD. Particularly useful in the very aggressive, impulsive, hostile, hyperactive ADHD children. Does not increase attention to the extent that stimulants do Side effects : Sedation Depression Hypotension Headache Dizziness, N & V Stomach ache Needs cardiovascular evaluation before use (EKG, etc.). Monitor BP after starting clonidine Need to titrate dose slowly to minimize side effects May be difficult, small tablets. ?pharmacy prepared elixir patch Available dosages Catapress tablets : 0.1, 0.2, 0.3 mg Catapress TTS (patch) : 0.1mg/day, 0.2mg/day, 0.3mg/day No drug holidays - rebound hypotension. Also used in combination with Ritalin Help with aggressivity ? Help with Ritalin rebound Tricyclic Antidepressants Most commonly used TCA's in ADHD Tofranil (imipramine) Norpramin (desipramine) Has been demonstrated to improve Sx of ADHD Used in older children Needs good cardiovascular evaluation Baseline and follow-up EKGs May be particularly helpful for those with depression/anxiety Side effects dry mouth gastric distress constipation urinary retention fatigue Start with lower doses than used in depression, adjust slowly upward Others: SSRIs Prozac, Zoloft & Paxil Exciting new class of drugs Being studied for ADHD in adults and children Low incidence of side effects Wellbutrin (buproprion) Has been studied for adult ADHD Effective Buspar (buspirone) Benzodiazapenesn. Growth retardation - More an indirect side effect as realized by individuals.