Download Psychopharmacological interventions for ADHD

ADHD in the Home:
Interventions and Strategies
Dr. Charles Pemberton, Ed.D, LPCC
Introduction
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Charles Pemberton
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Ed.D. in Educational Counseling
16 years in Counseling and Mental Health
Presented in England, South Africa, Central
America, and US.
Professor – UL and JCTCS
Private Practice – 60% children and families
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ADHD
Depression
Aggression
Anxiety
Today’s Schedule
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Diagnosis and Identification
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Treatment
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Comorbid disorders
Behavioral Modification
Medication
Tools and Resources
Questions
What won’t you get today
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A plan that will work everywhere with
everyone
Complete picture of medications
Causes of ADHD
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Biological Disorder
Neurological – dopamine/norepinephrine
Genetic
Toxins
Head injuries
No evidence:
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Sugar
Food additives
Allergies
Immunizations
Diagnosis Attention Deficit/Hyperactivity
Disorder
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Diagnostic and Statistical Manual IV- TR
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DSM- IV-TR
Within the “Disorders Usually First Diagnosed
in Infancy, Childhood, or Adolescence”
grouping, then subgrouped by the category of
“disruptive or self injurious behavior”
ADHD, Major Diagnostic Features
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Often will not complete tasks
Easily distracted by minor stimuli
Work often messy and completed w/o thought
Forgetful in day-to-day activities
Impulsive (interrupting others, cannot wait turn,
etc.)
Fidgetiness
Excessive talking
Subtypes of ADHD
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314.01 ADHD, Combined Type
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314.00 ADHD, Inattentive Type
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Classical ADHD
Old ADD
Seen more in girls
314.01 ADHD, Hyperactive-Impulsive Type
314.9 ADHD NOS
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Prominent symptoms but do not meet diagnostic criteria
Diagnostic Criteria for ADHD inattention
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A 1. Must exhibit 6 or more symptoms of
inattention, persisting for minimum of 6 months:
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fails to give close attention to details
often has difficulty sustaining attention
often does not seem to listen when spoken to directly
often has difficulty organizing tasks and activities
often loses things necessary for tasks
often easily distracted by extraneous stimuli
often forgetful in daily activities
Diagnostic Criteria - Hyperactive
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A 2. Must exhibit 6 or more symptoms of
hyperactivity-impulsivity, persisting for minimum of 6
months
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often fidgets with hands or feet or squirms in seat
often leaves seat in classroom
often runs about or climbs excessively
is often "on the go" or often acts as if "driven by a motor“
often talks excessively
often blurts out answers
often has difficulty awaiting turn
often interrupts or intrudes on others
Diagnostic Criteria, cont’d:
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B. symptom onset PRIOR to age 7 years
C. impairment present in two or more
environments
D. clear clinically significant impairment in
functioning
E. cannot be accounted for by other mental
disorder
Prevalence
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What percentage of children “should” be
diagnosed with a form of ADHD?
Prevalence of ADHD
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Estimated at 3-7% of school age children
More common in males than females
Often diagnosed during elementary school
years.
Co morbidity
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Oppositional Defiance Disorder
Conduct disorder
Mood Disorder
Anxiety Disorder
Learning Disorder
Tourettes
Hx abuse or neglect, multiple foster homes,
lead poisoning, Mental Retardation
Types according to Dr. Amen
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Type 1: Classic ADD
Restlessness, hyperactivity, constant motion,
troubles sitting still, talkative, impulsive behavior,
lack of thinking ahead .
Type 2: Inattentive ADD
Short attention span (especially about routine
matters), distractibility, disorganization,
procrastination, poor follow-through/task
completion.
Types con’t
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Type 3: Overfocused ADD
Worrying, holds grudges, stuck on thoughts,
stuck on behaviors, addictive behaviors,
oppositional/argumentative.
Type 4: Limbic ADD
Sad, moody, irritable, negative thoughts, low
motivation, sleep/appetite problems, social
isolation, finds little pleasure.
Types con’t
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Type 5: Temporal Lobe ADD
Inattentive/spacey/confused, emotional instability,
memory problems, periodic intense anxiety, periodic
outbursts of aggressive behavior seemingly triggered by
small events or intense angry criticisms directed at
himself for failures and frustrations, overly sensitive to
criticism and slights by others, frequent headaches
and/or stomachaches, learning difficulties, and serious
misperceptions/distortions of people and situations.
Types con’t
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Type 6: Ring of Fire ADD
A ring of overactivity in the brain scan image
which surrounds most of the brain is the source
of the name for this type of ADD.
too many thoughts, very hyper behavior, very
hyper verbal expressiveness, a hypersensitivity
to light, sound, taste, or touch.
Amen’s interventions
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Type 1: Classic ADD
Stimulant medication (Ritalin, Adderall, etc.),
a diet with more protein and less
carbohydrates, intense aerobic exercise.
Type 2: Inattentive ADD
Stimulant medication, perhaps stimulating
antidepressants (Welbutrin, for example), a
diet with more protein and less
carbohydrates, intense aerobic exercise.
Amen’s interventions
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Type 3: Overfocused ADD
An antidepressant that has a dual focus on two
brain transmitters (seratonin and dopamine)
(Effexor, for example), and/or an antidepressant
that enhances seratonin (Prozac, Zoloft, Paxil, or
others, for example). A stimulant medication may
need to be added. A diet with less protein and
increased complex carbohydrates will help, along
with intense aerobic exercise.
Amen’s interventions
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Type 4: Limbic ADD
An antidepressant that is also stimulating
(Effexor or Welbutrin, for example), with a
stimulant medication could be added; a
balanced diet, and intense exercise.
Amen’s interventions
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Type 5: Temporal Lobe ADD
Anticonvulsant medication (Neurontin, Depakote for
example), a stimulant could be added; a diet with
more protein and less simple carbohydrates.
Type 6: Ring of Fire ADD
Anticonvulsant medication (Neurontin, Depakote for
example, a stimulant medication could be added;
sometimes some of the newer, different antipsychotic medications may help (Risperdal, or
Zyprexa); a diet with more protein and less simple
carbohydrates.
Assessment – Am. Acad. Of
Pediatrics
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Evaluate any child 6 to 12 years of age who shows signs of
school difficulties, academic underachievement, troublesome
relationships with teachers, family members, peers, and other
behavioral problems.
Use DSM-IV criteria; these require that ADHD symptoms be
present in 2 or more of a child's settings, and that the symptoms
adversely affect the child's academic or social functioning for at
least 6 months.
Requires information from parents or caregivers and a teacher or
other school professional regarding core symptoms of ADHD in
various settings, age of onset, duration of symptoms, and degree
of impairment.
Assessment for co-existing conditions: learning and language
problems, aggression, disruptive behavior, depression or anxiety.
Assessment Tools
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No test available
Dx by:
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Observation
Rating Scales
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Vanderbilt
Conner’s
SNAP
How do we treat ADHD?
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Behavior Modification
Medication
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Differences
Dosages
Timing
Side-effects
Efficacy
Behavior Modification
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Home and Classroom
Basics of Behaviorism
Academics
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Take medication while doing homework
Set a schedule to work on homework
Minimize distractions
Establish “study buddy”
Use color to code calendar
Minimize spaces
Work on discovering what is really happening
Forgetting
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1- Need to notice
2- Need to write/record
3- Need to bring home
4- Need to look
5- Need to understand
6- Need to start/finish
7- Need to store
8- Need to turn-in
Academics cont’
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Divide into smaller segments
Use white noise
Use daily/weekly forms
Limit time spent on homework
Review for ‘hasty’ errors
Focus on school, remembering later
School Problems and symptoms
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Hyperactivity
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Depression
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Give study breaks
Reward completion
Allow movement – multiple P.E.
Focus on small successes
Provide support, not challenge to prove
Defiance
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Give choices
Teach problem solving
Lower voice
Use Time-out
Steps in Behavior Modification
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Identify behavior
Chart behavior for baseline
Identify motivators
Establish realistic goals
Match motivators with behavior changes
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Short term
Long term
Implement Plan
Evaluate Plan
Modify and repeat
Measurable/Realistic Goal
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Measurable Long term and Short Term Goals
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Who will measure?
What is the goal?
Where is the behavior now?
When will we measure?
How will we measure?
Consequences
Reward
Punishment
Positive
↑ behavior by ‘+‘
↓ behavior by ‘+‘
something
something
Negative
↑ behavior by ‘-‘
↓ behavior by ‘-‘
something
something
Consequences examples
Reward
Punishment
Positive
Add TV time when
no hitting
Add chores when
there is hitting
Negative
Take away chore
when there is no
hitting
Take away toy
when there is
hitting
Other Behavior Therapy techniques
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Token Economy
Time outs
Time-outs
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Not - “stand in corner”
Not punishment
Time to “cool off” and rethink
Procedure
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Call time out early
Establish time-in
Think about YOUR actions don’t prepare for battle
Classroom Rewards
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Homework reductions
Physical Contact
Computer Access
Additional recess
Free time in class
Tickets/stickers
Time to finish homework in class
Special pen or paper
Helping a child control his behavior
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Daily Schedule
Cut down distractions
Organize your house
Set small, reachable goals
Limit choices
Use calm discipline - distraction
Types of Medications
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Methylphenidate
Dextroamphetamine
Atomoxetene
Dexmethylphenidate
Antidepressants
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SSRI’s
Tricyclics
Basic Elements of Methylphenidate
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Known as: Ritalin, Ritalin SR, Ritalin LA, Concerta,
Metadate ER, Metadate CD, Focalin
Pharmacology: It is a CNS stimulant, which is
chemically related to amphetamine
Preparations – 5, 10, 20 mg tabs; sustained release
20 mg tabs; LA 20, 30, and 40 mg capsules. The SR
tablet should be swallowed and not crushed or
chewed. Concerta comes in 18 and 36 mg extended
release tablets. Metadate CD 20 mg capsules;
Metadate ER 10 – and 20 – mg tabs. Focalin 2.5, 5-, 10 - mg tabs.
Methylphenidate, cont’d
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Half-Life – 3-4 hours; 6-8 hours for sustained
release
It’s a schedule II controlled substance,
requiring a triplicate prescription
Pre-Drug Work-Up
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Blood pressure and general cardiac status
baseline and periodic blood counts and liver
function tests
Weight and growth should be monitored in
children
Methylphenidate, cont’d
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Adverse Drug Reactions
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Nervousness and insomnia; can be reduced by decreasing
dose.
Cardiovascular – Hypertension, tachycardia, and
arrhythmias.
CNS – Dizziness, euphoria, tremor, headache, precipitation
of tics and Tourette’s syndrome, and rarely psychosis.
GI – Decreased appetite, weight loss.
Case reports of elevated liver enzymes and liver failure.
Hematological –Leukopenia and anemia have been
reported
Growth Inhibition
Basic Elements of Dextroamphetamine
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Known as: Adderall, Adderall XR
Pharmacology:causes the release of
norepinepherine from neurons. At higher
doses, it will also cause dopamine and
serotonin release
Preparations – Adderall 5-, 7.5-, 10-, 12.5-,
15-, 20-, 30-mg tablets; Adderall XR 5-, 10-,
15-, 20-, 25-, 30-mg capsules.
Dextroamphetamine, cont’d
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Half-Life – 10-25 hours
It’s a schedule II controlled substance, requiring a
triplicate prescription
Pre-Drug Work-Up
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Blood pressure and general cardiac status should be
evaluated prior to initiating dextroamphetamine.
Can precipitate tics
Contraindicated in in patients with hypertension,
hyperthyroidism, cardiac disease or glaucoma. It is not
recommended for psychotic patients ot patients with a
history of substance abuse.
Weight and growth should be monitored in all children.
Dextroamphetamine, cont’d
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Adverse Drug Reactions
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Side effects – most common side effects are psychomotor
agitation, insomnia, loss of appetite, and dry mouth.
Tolerance to loss of appetite tends to develop. Effect on
sleep can be reduced by making sure no drug is given after
12 pm.
Cardiovascular – Palpitations, tachycardia, increased blood
pressure.
CNS – Dizziness, euphoria, tremor, precipitation of tics,
Tourette’s syndrome, and rarely, psychosis.
GI – Anorexia and weight loss, diarrhea, constipation.
Growth inhibition
Basic Elements of Atomoxetene
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Known as: Strattera
Pharmacology:works via presynaptic
norepinepherine transporter inhibition
Preparations – 10, 18, 25, 40, and 60 mg
capsules .
Atomoxetene, cont’d
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Half-Life – approximately 4 hours
Not a schedule II controlled substance
Clinical Guidelines –
 Dividing the dose may reduce some side effects
 Dose reductions are necessary in presence of moderate hepatic
insufficiency
 Atomoxetine should not be used within 2 weeks of
discontinuation of a MAO inhibitor.
 Atomoxetine should be avoided inpatients with narrow angle
glaucoma and, it should be used with caution in patients with
tachycardia, hypertension, or cardiovascular disease.
 It can be discontinued without taper.
 Pregnancy C category.
Atomoxetene, cont’d
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Adverse Drug Reactions
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Cardiovascular – increased blood pressure and
heart rate (similar to those seen with conventional
psychostimulant).
BI – Anorexia, weight loss, nausea, abdominal
pain.
Miscellaneous – Fatigue, dry mouth, constipation,
urinary hesitancy and erectile dysfunction.
Basic Elements of Dexmethylphenidate
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Known as: Focalin, Focalin XR
Pharmacology:causes the release of
dopamine from neurons. Is an isomer of
Ritalin.
Preparations – Focalin 2.5, 5 ,10-mg tablets;
Focalin XR 5-, 10-, 20-mg capsules.
Dexmethylphenidate, cont’d
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Half-Life – 2.2 hours
It’s a schedule II controlled substance, requiring a
triplicate prescription
Pre-Drug Work-Up
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Blood pressure and general cardiac status should be
evaluated prior to initiating Dexmethylphenidate.
Can precipitate tics
Contraindicated in in patients with hypertension,
hyperthyroidism, cardiac disease or glaucoma. It is not
recommended for psychotic patients or patients with a
history of substance abuse.
Weight and growth should be monitored in all children.
Dexmethylphenidate, cont’d
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Adverse Drug Reactions
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Side effects – most common side effects are psychomotor
agitation, insomnia, loss of appetite, and dry mouth.
Tolerance to loss of appetite tends to develop. Effect on
sleep can be reduced by making sure no drug is given after
12 pm.
Cardiovascular – Palpitations, tachycardia, increased blood
pressure.
CNS – Dizziness, euphoria, tremor, precipitation of tics,
Tourette’s syndrome, and rarely, psychosis.
GI – Anorexia and weight loss, diarrhea, constipation.
Growth inhibition
Release Characteristics
Concerta
Metadate
CD
Ritalin LA
Immediate
Release
22%
30%
50%
Delayed
Release
78%
70%
50%
Technology
Oros
Eurand
SODAS
Other Medications
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Dexadrine
Cylert
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Since marketing in 1975, 13 cases of acute hepatic failure
have been reported to the FDA. 11 resulted in death or
transplant.
Attenade
Paxil
Wellbutrin
Zoloft
Trileptal
Celexa/Lexapro
Effexor
When to use, when to change
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Side effects
Past history
Substance abuse
Efficacy
Onset time
Stimulant first line, Strattera second
Follow MD
Closing Thoughts
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Stimulants still first line defense
Look at choice of drug based upon time of
release
Be aware of study sponsor
Addictive nature
Subscribe to Medscape
Tools/Resources
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ADD/ADHD Behavior-Change Resource Kit
Teenagers with ADD: A Parents’ Guide
www.myadhd.com
www.adhdhelp.com
www.amenclinic.com
ADDitude Magazine
References
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American Academy of Pediatrics. Diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder.
Pediatrics. 2000;105:1158-1170.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. DSM-IV-TR. In: Disorders
Usually First Diagnosed in Infancy, Childhood, or Adolescence: Diagnostic Criteria for Attention-Deficit/Hyperactivity
Disorder. Washington, DC: American Psychiatric Association; 1994:92-93.
National Institute of Mental Health. National Institutes of Health. Attention deficit hyperactivity disorder. Available at:
http://www.nimh.nih.gov/publicat/helpchild.cfm. Accessed April 19, 2002.
U.S. Department of Health and Human Services. Mental Health: A Report of the Surgeon General. Available at:
http://www.surgeongeneral.gov/library/mentalhealth/chapter3/sec4.html. Accessed April 19, 2002.
Dulcan M. Practice parameters for the assessment and treatment of children, adolescents, and adults with attentiondeficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 1997;369(suppl):855-1215.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. DSM-IV-TR. In: Disorders
Usually First Diagnosed in Infancy, Childhood, or Adolescence: Diagnostic Criteria for Attention-Deficit/Hyperactivity
Disorder. Washington, DC: American Psychiatric Association; 1994:92-93.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. DSM-IV-TR. In: Disorders
Usually First Diagnosed in Infancy, Childhood, or Adolescence: Diagnostic Criteria for Attention-Deficit/Hyperactivity
Disorder. Washington, DC: American Psychiatric Association; 1994:92-93.
National Institute of Mental Health. National Institutes of Health. Attention deficit hyperactivity disorder—questions and
answers. Available at: http://www.nimh.nih.gov/publicat/adhdqa.cfm. Accessed April 19, 2002.
National Institute of Mental Health. National Institutes of Health. Attention deficit hyperactivity disorder—questions and
answers. Available at: http://www.nimh.nih.gov/publicat/adhdqa.cfm. Accessed April 19, 2002.
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision.
Washington, DC, American Psychiatric Association, 2000.
Fauman, M. A. (2002). Study Guide to DSM-IV-TR. Washington, DC: American Psychiatric Publishing, Inc.
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www.pembertoncounseling.com