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CHILD ADOLESCENT ADHD SYMPTOMS, DIAGNOSIS AND TREATMENT

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  1. CHILD ADOLESCENT ADHD SYMPTOMS, DIAGNOSIS AND TREATMENT John R. Sealy, M.D., D.L.F.A.P.A. SEPTEMBER 15, 2009

  2. DISCLOSURES • Speaker for McNeil, Shire • Own stocks in Johnson and Johnson, Shire, Novartis

  3. WHAT IS ADHD? ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD) IS A COMMON CHRONIC PERSISTENT NEUROBEHAVIORAL DISORDER WITH ONSET OF SYMPTOMS BEFORE AGE 7, DEVELOPMENTALLY INAPPROPRIATE LEVELS OF INATTENTION AND/OR HYPERACTIVITY AND IMPULSIVITY AND CLINICALLY SIGNIFICANT IMPAIRMENT IN 2 OR MORE SETTINGS (AT SCHOOL, AT HOME, AND IN PEER SETTINGS)

  4. “HYPERFOCUS”ON THE FLIP SIDE, THEHALLMARK SYMPTOM OF ADHD IS THE PHENOMENON OF “INTERESTED BASE PERFORMANCE”. THAT IS, PEOPLE WITH ADHD CAN PERFORM AT A VERY HIGH LEVEL AS LONG AS THEY FIND THE WORK INTERESTING, CHALLENGING AND NOVEL 1 1.Flippin, R., Breaking the Spell of Hyperfocus, ADDitude. 2005; Oct/Nov:33-34

  5. HYPERFOCUS • HYPERFOCUS CAN BE SO STRONG AT TIMES, THAT AN ADHD PERSON CAN BE OBLIVIOUS TO THE WORLD AROUND THEM, EG. VIDEO GAMES, TV, SHOPPING, SURFING THE INTERNET • HOURS CAN DRIFT BY AS IMPORTANT TASKS AND RELATIONSHIPS FALL BY THE WAYSIDE 1.Flippin, R., Breaking the Spell of Hyperfocus, ADDitude. 2005;Oct/Nov:33-34

  6. ADHD IS BETTER SEEN AS A DISREGULATED ATTENTION SYSTEM • LIKE DISTRACTIBILITY, HYPERFOCUS HAS BEEN THOUGHT TO RESULT FROM ABNORMALLY LOW LEVELS OF DOPAMINE IN THE PRE-FRONTAL CORTEX. NEW EVIDENCE SUGGESTS, NOREPINEPHRINE LEVELS ALSO PLAY AN IMPORTANT ROLE • THIS MAKES IT HARD TO “SHIFT GEARS” TO TAKE UP BORING-BUT-NECESSARY TASKS • R. BARKLEY, PHD, AGREES THAT ADHD PEOPLE HAVE DIFFICULTY WITH CONTROLLED SHIFTING OF ATTENTION FOR ONE THING TO ANOTHER.

  7. IN GENERAL,CHILDREN AND ADOLESCENTS WITH ADHD • LIVE OUTSIDE OF TIME • LIVE IN THE HERE AND NOW • HAVE POOR PLANNING SKILLS • DO NOT FOCUS IN A LINEAR PROGRESSION • HAVE POOR SHORT TERM or WORKING MEMORY

  8. THE PREFRONTAL CORTEX REGULATES ATTENTION, BEHAVIOR AND EMOTION IN THREE SUB-REGIONS • DORSOLATERAL PFC • THE RIGHT INFERIOR PFC • THE VENTROMEDIAL PFC

  9. ADHD IS SEEN AS A CHEMCIAL IMBALANCE IN PRE-FRONTAL CORTEXAFFECTING WORKING MEMORY DORSO-LATERAL PFC INHIBITORY PROJECTIONS TO PARIETAL, TEMPORAL AND OTHER MANTLE CORTICES ARE THOUGHT TO REGULATE ATTENION 1.Chao LL, Knight RT. Neuroreport. 1995;6:1605-1610 2.Woods, DL, Knight RT. Neurology. 1986; 36:212-216 3.Wilkins, AJ, et al. Neuropsychologia. 1987;25:3590365 4.Amsten AFT, et al. J. Child Adolesc Psychopharmacol. 2007; 17:393-406

  10. ADHD IS SEEN AS A CHEMCIAL IMBALANCE IN PRE-FRONTAL CORTEXAFFECTING WORKING MEMORY RIGHT INFERIOR PFC PROJECTIONS INTO THE MOTOR AND PREMOTOR CORTICES, BASAL GANGLIA AND CEREBELLUM VIA PONS ARE THOUGHT TO BE INVOLVED IN BEHAVIOR INHIBITION. IMPAIRMENT MAY LEAD TO SYMPTOMS OF IMPULSIVITY AND HYPERACTIVITY 1.Aron AR, Poldrack RA. Biol Psychiatry. 2005;57:1285-1292 2.Aron AR, et al. Trends Cogn Sci. 2004;8:170-177 3.Amsten AFT, et al. J. Child Adolesc Psychopharmacol. 2007; 17:393-406

  11. ADHD IS SEEN AS A CHEMCIAL IMBALANCE IN PRE-FRONTAL CORTEXAFFECTING WORKING MEMORY THE VENTORMEDIAL PFC IS THOUGHT TO REGULATE EMOTION THROUGH THE BASAL GANGLIA, AMYGDALA, HYPOTHALAMUS AND BRAINSTEM. IMPAIRMENT MAY LEAD TO AGGRESSIVE AND OPPOSITIONAL BEHAVIOR. 1.Anderson SW, et al. Nat Neuorsci. 1999;2:1032-1037 2.Amsten AFT, et al. J. Child Adolesc Psychopharmacol. 2007; 17:393-406 3.Price KL, et al. Prog Brain Re. 1996;107:523-536

  12. IMPULSIVE BEHAVIOR IN CHILD/ADOLESCENT ADHD MAY LEAD TO: • POOR DECISION MAKING • POOR LISTENING, TENDENCY TO INTERRUPT • IMPULSIVE BEHAVIOR • LOW TOLERANCE FOR FRUSTRATION, QUICK TO ANGER • POOR PEER RELATIONSHIPS • RECKLESS DRIVING, SPEEDING • DIFFICULTY WAITING TURN (LINES, TRAFFIC) • RISKY SEXUAL BEHAVIOR

  13. HYPERACTIVITY IN CHILD/ADOLESCENT ADHD MAY CAUSE: • FIDGETING OF HANDS AND FEET • INNER SENSE OF RESTLESSNESS • EXCESSIVE TALKING • INABILITY TO SIT STILL FOR LONG PERIODS (e.g. THROUGH CLASSES, HOMEWORK, CONVERSATIONS.)

  14. INABILITY TO SUSTAIN ATTENTION IN CHILD/ADOLESCENT ADHD MAY LEAD TO: • POOR ACADEMIC OR JOB PERFORMANCE • DEFICIENT READING COMPREHENSION • DISTRACTIBILITY • INABILITY TO FOLLOW DIRECTIONS, COMPLETE TASKS • PROCRASTINATION, TROUBLE INITIATING TASKS • FORGETFULNESS • UNRELIABILITY

  15. ADHD HISTORICAL TIMELINE • IN 1798, CRICHTON WROTE A CHAPTER ON ATTENTION AND BEHAVIOR REGULATION USING ANECDOTAL DESCRIPTIONS OF PATIENTS WHO HAD “THE FIDGETS” • 1902 PEDIATRICIAN STILL PRESENTED 3 PAPERS ON A ATTENTION AND EMOTIONAL DYSREGULATION IN CHILDREN • 1971 WENDER DESCRIBED MINIMAL BRAIN DYSFUNCTION

  16. ADHD IN PEDIATRIC PATIENTS OFTEN PERSISTS INTO ADULTHOOD1 • ALTHOUGH SOME SYMPTOMS (PARTICULARLY MOTOR HYPERACTIVITY) MAY LESSEN DURING ADULTHOOD OTHERS ARE OFTEN ASSOCIATED WITH IMPAIRMENTS IN FUNCTIONAL DOMAINS (WORK, HOME SOCIAL SITUATIONS)2 1.Pliska, S et al, J Am Acad Child Psychiatry 2007:46:894-921 2. American Psychiatric Assoc. DSM IV, 4th ED, Text Rev. Washington,DC:American Psychiatric Assoc:2000

  17. ADHD IS A VALID DIAGNOSIS • ADULTS WITH ADHD HAD SIGNIFICANT IMPAIRMENT IN AUDITORY SUSTAINED ATTENTION AND EXECUTIVE COMPONENTS OF VERBAL LEARNING AND ARITHMETIC SEIDMAN ET AL (1998) • A LARGE PERCENTAGE OF LONGITUDINAL FOLLOW-UP STUDIES SHOWED YOUNGSTERS CONTINUED TO HAVE IMPAIRING ADHD SYMPTOMS INTO ADOLESCENCE AND ADULT HOOD SPENCER ET AL (2002) • ADULTS WITH ADHD HAVE A HIGH LEVEL OF POSITIVE RESPONSE TO THE SAME STIMULANT AND NON-STIMULANT TREATMENTS USED WITH CHILDREN FARAONE ET AL (2004)

  18. PREVALANCE OF ADHD • PREVALANCE OF ADHD IS ESTIMATED AT 3% TO 7% IN SCHOOL-AGED CHILDREN DSM IV, 4TH ED • UP TO 65% WILL EXHIBIT SYMPTOMS IN ADULTHOOD1 • PREVALANCE OF ADHD IN ADULTS = 4.4% KESSLER ET AL. • 1.DULCAN M et al, J AM ACAD CHIL ADOLESC PSYCHIATRY, 1997:36 (SUPPL):85S-121S • 2.KESSLER ET AL, AMER J PSYCHIATRY 2006;163:716-723

  19. ADHD HAS STRONG GENETICUNDERPINNINGS • FAMILY STUDIES SHOW PARENTS OF ADHD CHILDREN ARE 2 TO 8 TIMES MORE LIKELY TO HAVE ADHD THEMSELVES (FARAONE+TSUANG, 1995) • HIGHER RATES OF ADHD AMONG RELATIVES, EVEN AS ADHD CRITERIA HAVE CHANGED OVER TIME (BIEDERMAN ET AL 1990; FAFARONE ET 2000) • TWIN STUDIES SUGGEST APPROXIMATELY 80% HERITABILITY FOR ADHD AND ADOPTION STUDIES SHOW CONSISTENTLY HEREDITY IS CENTRAL IN TRANSMISSION (WILENS ET AL, 2002)

  20. CONSEQUENCES OF UNTREATED CHILD/ADOLESCENT/ADULT ADHD AS COMPARED WITH NORMAL CONTROLS • MORE GRADE RETENTION (42% vs 13%) • LOWER GRADE POINT AVERAGES(1.7vs2.6) • HIGHER DROPOUT RATES (32% vs 0%) • HIGHER SUSPENSION RATES (60% vs 19%) • LOWER COLLEGE ENTRANCE (22% vs 77%) • LOWER COLLEGE GRADUATION(5%vs35%) • IN WORK FORCE, LOWER WORK PERFORMANCE, MORE LIKELY TO BE FIRED AND HIGHER JOB TURNOVER • BARKLEY, R ET AL, ADHD IN ADULTS, pp 130-169 GUILFORD PRESS 2008

  21. CONSEQUENCES OF UNTREATED CHILD/ADOLESCENT/ADULT ADHD AS COMPARED WITH NORMAL CONTROLS • 2X HIGHER RISK FOR TOBACCO SMOKING • 2.5X HIGHER RISK FOR ALCOHOL ABUSE • 2X HIGHER RISK FOR SUBSTANCE ABUSE • 4X MORE LIKELY TO CONTRACT STD’S • 10X HIGHER RISK FOR UNPLANNED PREGNANCY • 2X TO 6X HIGER RATE FOR SUSPENDED OR REVOKED DRIVER’S LICENSE, MORE TRAFFIC VIOLATIONS, SPEEDING TICKETS, ACCIDENTS, AUTO DAMAGE • BARKLEY, R ET AL, ADHD IN ADULTS WHAT THE SCIENCE SAYS, pp 130-169 GUILFORD PRESS 2008

  22. CONSEQUENCES OF UNTREATED ADULT ADHD AS COMPARED WITH NORMAL CONTROLS • EMPLOYERS RATE ADHD EMPLOYEES AS HAVING VERY LOW PRODUCTIVITY AND HIGH RATES OF ABSENTEEISM • HIGH RATES OF MOTOR VEHICLE ACCIDENTS • COST FOR MEDICAL CARE TWICE AS HIGH FOR ADULTS WITH ADHD • INCREASED SEXUAL AND REPRODUCTIVE RISKS

  23. DIAGNOSIS OF ADHD

  24. CLINICAL DIAGNOSIS OF ADHD • SYMPTOM ASSESSMENT IS IMPORTANT, BUT CHRONICITY, PERVASIVENESS, AND IMPAIRMENT ARE CRITICAL TO DIAGNOSISDSM IV 4TH ED TR • DIAGNOSIS BASED ON CLINICAL ASSESSMENT -MEDICAL HISTORY1 -FAMILY HISTORY1 -ACADEMIC, SOCIAL, OCCUPATIONAL FUNCTIONING1 -RATING SCALES ASSIST IN ESTABLISHING SYMPTOMS1 -INTERVIEW WITH FAMILY MEMBERS IS HELPFUL1 1. Adler, L, Cohen, J. Psychiatr Clin NAm. 2004;27:187-201

  25. DIAGNOSING ADHD Based on DSM-IV-TR • DIAGNOSIS OF ADHD INCLUDES -6/9 INATTENTIVE AND/OR 6/9 HYPERACTIVE-IMPULSIVE SYMPTOMS PERSISTENT FOR AT LEAST 6 MONTHS -IMPAIRMENT IN MULTIPLE SETTINGS -CHILDHOOD ONSET BEFORE AGE 7 -SYMPTOMS NOT BETTER ACCOUNTED FOR BY ANOTHER MENTAL HEALTH DISORDER -CLEAR EVIDENCE OF CLINICALLY SIGNIFICANT IMPAIRMENT IN ACADEMIC, SOCIAL, OCCUPATIONAL FUNTIONING

  26. ADHD RATING SCALES FOR CHILDREN AND ADOLESCENTS • ACADEMIC PERFORMANCE RATING SCALE(APRS) • ATTENTION DEFICIT DISORDERS EVALUATION SCALE-3RD ED (ADDES-3)PARENT TEACHER • ADHD RATING SCALE-IV • CHILD BEHAVIOR CHECKLIST (CBCL) • CONNERS PARENT RATING SCALE-REVISED AND CONNER TEACHER RATING SCALE-REV

  27. ADHD RATING SCALES FOR CHILDREN AND ADOLESCENTS • CONNERS WELLS ADOLESCENT SELF-REPORT SCALE (CASS) • HOME SITUATIONS QUESTIONNAIRE-REVISED (HSQ-R) SCHOOL SITUATIONS QUESTIONNAIRE REVISED (SSQ-R) • INATTENTION/OVERACTIVITY WITH AGGRESSION (IOWA) CONNERS TEACHING SCALE • VANDERBILT ADHD DIAGNOSTIC PARENT AND TEACHER SCALE

  28. HIDDEN ADHD PRESENTATIONS • DEPRESSION THAT DOES NOT RESPOND TO ANTI-DEPRESSANTS • RELATIONSHIP COMPLAINTS • SEVERE CLUTTER • DRIVING COMPLAINTS • MEMORY COMPLAINTS • “DAYDREAMER” “ABSENT-MINDED” SELF-ESTEEM COMPLAINTS • ADDICTION TO MARIJUANA, NICOTINE, CAFFEINE, COCAINE, ALCOHOL • ANTISOCIAL BEHAVIOR

  29. BARKLEY’S FINDINGS CHALLENGE THE DSM-IV • 18 SYMPTOMS ARE NOT REQUIRED.WAS ABLE TO DX WITH 97% ACCURACY WITH ONE ITEM “OFTEN BEING EASILY DISTRACTED BY EXTRANEOUS STIMULI” • NEED TO SEPARATE IMPULSIVITY (ESPECIALLY VERBAL) AS A GREATER PROBLEM IN ADULTS • THE CRITERION OF 7 YEARS HAS NO SCIENTIFIC MERIT AND SHOULD BE INCREASED TO 14-16 YEARS OF AGE. URGES IGNORING 7 YEAR RULE • DSM-V MUST HAVE SEPARATE ADULT CRITERIA WITH SIX SYMPTOMS • BARKLEY, R.A., MURPHY K.R. AND FISCHER M. (2007). ADHD IN ADULTS:WHAT THE SCIENCE SAYS. NEW YORK:GUILFORD PRESS PP 128-129

  30. EVALUATION OF ADHD RULE OUT MEDICAL/PSYCHIATRIC CONDITONS THAT MIMIC OR MAY BE CO-MORBID WITH ADHD: HEAD TRAUMA/ HEARING IMPAIRMENT LEARNING DISORDERS NARCOLEPSY/ SLEEP DISORDERS/ SLEEP APNEA PETIT MAL SEIZURES/ ENCEPAHALOPATHY HYPOTHYROIDISM, HYPOGLYCEMIA BORDERLINE INTELLECTUAL FUNCTIONING PERSONALITY DISORDERS BIPOLAR DISORDER DEPRESSION/ANXIETY

  31. EXAMPLES OF SYMPTOMS THAT MAY MIMIC OR BE CO-MORBID WITH ADHD • RESTLESSNESS, IMPULSIVITY (HYPOMANIA IN BIPOLAR TYPE II) • FORGETFUL, POOR CONCENTRATION, SLUGGISH (SLEEP DISTURBANCE, HYPOTHYROID) • DIFFICULTY FOLLOWING DIRECTIONS, SLOW PROCESSING (LEARNING DISABILTIES) • IMPATIENCE, POOR CONCENTRATION (HYPOGLYCEMIA)

  32. MTA COMORBIDITY WITH ADHD7-10 YEARS OLD n=579 ANXIETY DISORDERS 34% OPPOSITIONAL DEFIANT DISORDER 40% CONDUCT DISORDER 14% TIC DISORDER 11% MOOD DISORDER 4% Jensen PS, Hinshaw SP, Kraemer HC, et al. ADHD comorbidity findings from the MTA study comparing comorbid subgroups. J AM Acad Child Adolesc Psychiatry. 2001;40(2):147-158

  33. ADHD INCREASES LIABILITY FOR OTHER PSYCHIATRIC DISORDERS “MORE THAN 80% OF OUR ADHD GROUPS HAD AT LEAST ONE OTHER DISORDER, MORE THAN 50% HAD TWO OTHER DISORDERS AND MORE THAN A ONE-THIRD HAD AT LEAST THREE OTHER DISORDERS” • BARKLEY, R.A., MURPHY K.R. AND FISCHER M. (2007). ADHD IN ADULTS:WHAT THE SCIENCE SAYS. NEW YORK:GUILFORD PRESS P 439

  34. EVALUATING LEARNING DISORDERS • LEARNING DISORDERS (e.g. READING DISORDER) GENERALLY DO NOT RESPOND TO MEDICATIONS1 • NEUROPSYCHOLOGICAL TESTING EVALUATES COGNITIVE STRENGTHS (e.g. GIFTEDNESS) AND WEAKNESSES (e.g. SLOW PROCESSING SPEED AND WORKING MEMORY) • 1. HINSHAW SP. J CONSULT CLIN PSYCHOL. 1992;60(6):893-903

  35. EVALUATION OF SUSPECTED ADHD REMEMBER, ADHD SYMPTOMS UNLIKE OTHER DIAGNOSES ARE ALWAYS: • PERVASIVE • PERSISTENT • PREDICTABLE

  36. COMMON DIAGNOSTIC MISTAKES • NOT TAKING ENOUGH TIME. MAY MISS IMPORTANT SECONDARY DIAGNOSIS • DIAGNOSING SYMPTOMS, NOT PRIMARY PROBLEM. ANXIETY/ DEPRESSION MAY BE SECONDARY TO ADHD • THINKING ACADEMIC FAILURE IS INTRINSIC TO ADHD. MANY CHILDREN DUE WELL BECAUSE THEY WORK SO HARD • THINKING HIGH IQ RULES OUT ADHD. CHILD MAY BE LABELED LAZY, UNDISCIPLINED, BUT SUFFER ADHD OR A LEARNING DISORDER

  37. WHY GIRLS ARE MORE LIKELY THAN BOYS TO GO UNDIAGNOSED OR MISDIAGNOSED • YOUNG GIRLS TRY HARDER TO COMPENSATE OR COVER UP SYMPTOMS • YOUNG GIRLS MORE WILLING TO PUT IN EXTRA HOURS OF STUDYING AND ASK FOR HELP • MORE LIKELY TO BE “PEOPLE PLEASERS” • TEACHERS OFTEN THINK ADHD IS A DISORDER OF HYPERACTIVITY IN BOYS • GIRLS COMMONLY DO NOT HAVE HYPERACTIVITY AND TEND TO BE LABELED “SPACY” OR “DAYDREAMERS”

  38. ADULT ADHD CONCERNS

  39. BARKLEY’S SUGGESTED CRITERIA FOR ADULT ADHD(AT LEAST 4 OF THE FIRST 7 OR 6 OF 9) • OFTEN IS EASILY DISTRACTED BY EXTRANEOUS STIMULI • OFTEN MAKES DECISIONS IMPULSIVELY • OFTEN HAS DIFFICULTY STOPPING ACTIVITIES OR BEHAVIOR WHEN HE OR SHE SHOULD DO SO. • OFTEN STARTS A PROJECT OR TASK WITHOUT READING OR LISTENING TO DIRECTIONS CAREFULLY • OFTEN SHOWS POOR FOLLOW-THROUGH ON PROMISES OR COMMITMENTS MADE TO OTHERS

  40. BARKLEY’S SUGGESTED CRITERIA FOR ADULT ADHD (CONTINUED)(AT LEAST 4 OF THE FIRST 7 OR 6 OF 9) 6. OFTEN HAS TROUBLE DOING THINGS IN THEIR PROPER ORDER OF SEQUENCE • OFTEN DRIVES A MOTOR VEHICLE MUCH FASTER THAN OTHERS. FOR NON DRIVERS, OFTEN HAS DIFFICULTY ENGAGING QUIETLY IN LEISURE OR ENJOYABLE ACTIVITIES • OFTEN HAS DIFFICULTY SUSTAINING ATTENTION IN TASKS OR RECREATIONAL ACTIVITIES • OFTEN HAS DIFFICULTY ORGANIZING TASKS AND ACTIVITIES. BARKLEY RA, MURPHY KR, FISCHER M. ADHD IN ADULTS:WHAT THE SCIENCE SAYS. NEW YORK, NY:GUILFORD PRESS;2008

  41. DIAGNOSTIC SCALES FOR ADULT ADHD ASSESSEMENT • CAADID (CLINICIAN ADMINISTERED) • BARKLEY’S CURRENT SYMPTOM SCALE-SELF REPORT FORM • BROWN ATTENTION-DEFICIT DISORDER (ADD) SCALES DIAGNOSTIC FORM • TOVA

  42. SYMPTOM RATING SCALES ADULT ADHD • CONNER’S ADULT ADHD RATING SCALE (CAARS) (www.mhs.com) • ADHD-RS-IV (18 ITEM RATING SCALE)(in syllabus with prompts) • BROWN ADD SCALE (Brown ADD-RS) (pearsonassess.com) • ADULT SELF-REPORT SCALE (ASRS) SYMPTOMCHECKLIST(www/med/nyu.edu/Psych/training/adhd.html) in syllabus

  43. OTHER SYMPTOM RATING SCALES ADULT ADHD • WENDER UTAH RATING SCALE • WENDER-REIMHERR ADULT ADD SCALE (WRAADS) ASSESSES MOOD LABILITY SX • DODSON CHECKLIST FOR ADULT ADHD

  44. TREATMENT OF CHILD/ADOLESCENT ADHD

  45. STIMULANT TREATMENT ALTHOUGH STIMULANTS ARE TREATMENT OF CHOICE FOR ADHD,1 ALL CHILDREN/ ADOLESCENTS ARE UNIQUE, THEREFORE, THERE IS NO ONE MEDICATION THAT FITS ALL PATIENTS 1. AMERICAN ACADEMY OF PEDICATRICS PEDIATRICS 2001, 108;1033-1044

  46. FDA APPROVED MEDICATIONS FOR ADHD • METHYLPHENIDATE FAMILY SHORT ACTING: RITALIN, METHYLIN, METHYLIN CHEWABLE, FOCALIN INTERMEDIATE ACTING: METADATE ER, METHYLIN ER, RITALIN SR, METADATE CD, RITALIN LA LONG ACTING: CONCERTA*, DAYTRANA • AMPHETAMINE FAMILY SHORT ACTING:DEXEDRINE, DEXTROSTAT, ADDERALL, LONG ACTING: DEXEDRINE SPANSULE, ADDERALL XR*, VYVANSE* • NON-STIMULANTS (ATOMOXETINE)STRATTERA * * APPROVED FOR ADULTS

  47. AMERICAN ACADEMY OF PEDICATRICS “SHORT-ACTING STIMULANTS OFTEN USED AS INITIAL TREATMENT IN SMALL CHILDREN (<16KG) BUT HAVE DISADVANTAGE OF BID OR TID DOSING TO CONTROL SYMPTOMS THROUGHOUT THE DAY. ONCE DAILY, LONG ACTING STIMULANTS ARE NOW RECOMMENED AS FIRST LINE MEDICATION.”

  48. CONCERTA DELIVERS METHYLPHENIDATE USING IMMEDIATE-RELEASE COATING AND DELAYED-RELEASE OSMOTIC MECHANISM 22% IMMEDIATE RELEASE 78% DELAYED RELEASE ONCE A DAY 12 HOUR SMOOTHER EFFECT THAN RITALIN BID OR TID LOWER ABUSE POTENTIAL

  49. METADATE CD • USES IMMEDIATE AND DELAYED RELEASE BEADS OF METHYLPHENIDATE WITHIN A CAPSULE TO PROVIDE 6 TO 8 HOURS OF EFFECT • HAS WIDE RANGE OF DOSES AVAILABLE. SOME REPORT FASTER ONSET OF ACTION • HELPFUL DURING SCHOOL HOURS. SHORTER ACTING ALLOWS MANAGEMENT OF APPETITE SUPPRESSION/WEIGHT LOSS ISSUES BECAUSE DINNER HOUR IS LESS AFFECTED.

  50. FOCALIN XR • USES IMMEDIATE AND DELAYED RELEASE BEADS OF DEX-METHYLPHENIDATE WITHIN A CAPSULE TO PROVIDE 10 TO 12 HOURS OF EFFECT • D-METHYLPHENIDATE IS THE ACTIVE ISOMER OF RACEMIC METHYLPHENIDATE(MPH) • TWICE AS POTENT AS METHYLPHENIDATE (WHICH HAS BOTH LEVO AND DEXTRO ISOMERS). USE ½ LOWER DOSING THAN MPH. • 10 TO 12 HOUR EFFECT