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WHAT TEACHERS NEED TO
    KNOW ABOUT
  ADHD MEDICATIONS




                        1
CREDITS
   Attention-Deficit/Hyperactivity Disorder
                   (ADHD)
             At the Leading Edge


                              Program Directors:
Emmett Francoeur, MD, FRCPC   Samuel Chang, MD, FRCPC                Grazyna Jackiewicz, MD, FRCPC
Associate Professor,          Clinical Associate                     Assistant
McGill University             Professor, University of Calgary       Professor, Pediatrics, McMaster
Director, Child Development   Director, Adolescent Substance         University
Program, McGill University    Abuse & Psychiatric Disorders Clinic   Consulting Pediatrician in
Health Center                 Psychiatrist, Foothills Medical        Developmental/Behavioural
Westmount, Quebec             Centre                                 Pediatrics, American Board Certified
                              Calgary, Alberta                       Chedoke Developmental/
                                                                     Behavioural Clinic,
                                                                     Hamilton, Ontario
                                                                     Private Practice,
                                                                     Niagara Falls, Ontario
ASSUMPTIONS

•   Co Morbidities
•   Prevalence
•   Causes
•   Symptoms
•   Assessment




                     3
SOCIETAL IMPORTANCE

•   Prevalence
•   Developmental Sequencing
•   Economics
•   Multijurisdictional Agency Involvement
•   Multimodal Management
•   Prevention



                                             4
ADHD is Most Likely Caused by a
                Complex Interplay of Factors


              Neuroanatomic
                                                                                                            Genetic origins
              Neurochemical



                                                              ADHD
                 Environmental
                 factors                                                                                        CNS insults



Swanson JM, et al. Mol Psychiatry. 1998;3(1):38-41. Swanson JM, et al. Lancet. 1998; 351(9100):429-33. Milberger S, et al. Biol Psychiatry. 1997;41(1):65-
                                           75. Castellanos FX, et al. Arch Gen Psychiatry. 1996;53(7):607-16.                                                5
ADHD Impacts Domains of Function

                                                            Difficulty With:

                       Before
                                                         School                           After School                              Bedtime
                       School


    • Waking up                       • Lower grades                     • Sports/Clubs                             • Bedtime prep
    • Getting ready for • Lack of focus                                  • Homework                                 • Settling down
      school            • Disruptive                                     • Risky behavior                             and falling asleep
    • Struggling        • Difficulty with                                  and injuries
      excessively         friendships                                    • Sitting through dinner
      with parents
                                                                         • Family interactions




Barkley RA, et al. J Am Acad Child Adolesc Psychiatry. 1990;29(4):546-57. Barkley RA. J Clin Psychiatry. 2002;63(Suppl 12):S10-5. DuPaul GJ, et al. J Am
 Acad Child Adolesc Psychiatry. 2001;40(5):508-15. Greenhill LL. J Clin Psychiatry. 1998;59(Suppl 7):S31-41. Weiss G, et al. J Am Acad Child Psychiatry    6
                                                                   1985;24(2):211-20.
ADHD Impacts Social Functioning



                                                                            Problems
                                                                            • Problems with the justice system
                                                                            • Family conflicts
                                                                            • Early and impulsive sexuality
                          +            ADHD                                 • Tobacco and substance abuse
                                                                            • Accidents and injuries
                                                                            • Interpersonal difficulties
                                                                            • School and professional difficulties




  American Academy of Pediatrics. Pediatrics. 2000:105(5);1158-70. Barkley RA, et al. Clinical Child and Family Psychology Review. 2002;5(2):89-111.
Barkley RA. In: Barkely RA, ed. Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment, Third Edition. New York; Guilford,   7
                                                                         2006.
Evidence for Frontal Lobe Deficits

•Deficits on Executive Function Tests
•Less Frontal Electrical Activity (QEEG, EEG, EP)
•Reduced Blood Flow to Frontal and Striatal Regions
(SPECT; Altropane Uptake)
•Diminished Frontal and Striatal Metabolic Activity
(PET and fMRI)
•Smaller Frontal-Basal Ganglia-Cerebellar Areas (MRI)




                                                        8
Development and Progressive
   Cortical Cell Density




                              9
Executive Functions Often
                                        Impaired in ADHD
                                                          Executive Functions



Organizing              Focusing,                 Regulating                 Managing           Utilizing   Monitoring
prioritizing,          sustaining                 alertness,                 frustration        working      and self-
    and                focus, and                 sustaining                    And             memory      regulating
 activating              shifting                 effort, and                modulating           And         action
  to work               focus to                  processing                  emotions         accessing
                          tasks                     speed                                        recall




    1.                        2.                       3.                        4.               5.            6.
Activation                  Focus                     Effort                   Emotion          Memory        Action




  Brown TE. 2001. Manual for Attention Deficit Disorder Scales for Children and Adolescents.                             10
Clinical Presentation of ADHD in
       Adolescents

                      ADHD Symptoms in Adolescents
May have a sense of inner                              Procrastinates and displays
restlessness rather than hyperactivity                 disorganized school work with poor
                                                       follow-through
Fails to work independently                            Poor peer relationships
Poor self-esteem
Inability to delay gratification                       Specific learning disabilities

Behaviour not usually modified by                      Engages in ―risky‖ behaviour
reward or punishment                                   (speeding, unprotected sex, substance
                                                       abuse)
Apparent disregard for own safety                      Difficulties or clashes with authority
(injuries and accidents)

                            Greenhill LL. J Clin Psych. 1998;59(Suppl 7):31-41.
                                                                                                11
Persistance of Disorder
   •Symptoms decrease somewhat with age
   •Adolescence: (Based on Parent reports)
       •50% persistence to adolescence (1970-80s)
       •70-80% in modern DSM studies (1990s onward)
   •Young Adulthood (age 20-26) (Barkley et al. 2002)
       •Depends on who you ask (self vs. parents)
       •3-8% Full disorder (self-report using DSM III R
       •46% Full disorder (parent reports using DSM III R)
       •12% - Using 98th percentile (+2SDs; self-report)
       •66% - Using 98th percentile (parent report)
                    •Parent reports have greater veracity—they correlate more highly with various domains
                    of major life activities than do self reports
           •85-90% remain functionally impaired




Barkley RA. 2003. Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment
                                                                                                            12
Role of teachers
•   Observer
•   Reporter (report cards)
•   Manager
•   Parent liaison
•   Health Care liaison
•   Monitor




                              13
ADHD Management Goals
• Treat ADHD throughout the lifespan
• Treat symptoms throughout the full day in
  multiple areas of a patient‘s daily life
        No longer sufficient to treat during the school
         day or work hours
• Develop collaboration between home and
  school



Connor DF. In: Barkley RA, ed. Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment, Third Edition. New
  York; Guilford, 2006. Canadian Attention Deficit Hyperactivity Disorder Resource Alliance (CADDRA): Canadian ADHD Practice          14
                                       Guidelines, First Edition. Toronto, ON; CADDRA, 2006.
ADHD Management Strategies
• Psychoeducation
       Give local resources, written material and web based
        resources
• Psychosocial interventions
       Classroom intervention, family counselling, support
        groups
• Medications
       Mainstay of treatment, single most effective
        intervention, safe, effective and non addictive
       Not for children less than 6 years old (certain
        exceptions apply)

Canadian Attention Deficit Hyperactivity Disorder Resource Alliance (CADDRA): Canadian ADHD Practice Guidelines, First Edition.
                                                   Toronto, ON; CADDRA, 2006.                                                     15
MTA Study: Objective and Design
Objective: To compare the long-term efficacy of pharmacotherapy,
behavioral therapy, and combination therapy in the treatment of ADHD.

                                                                 Medication management
                                                               (primarily methylphenidate)
579 Children
ADHD, Combined type
Age Range: 7-9.9 years                                              Behavioral treatment

Randomly assigned
14-month study                                           Combination treatment: medication
                                                              and behavioral therapy



                                                                 Routine Community Care


                    MTA Cooperative Group. Arch Gen Psych. 1999;56:1073-1086.
                                                                                             16
MTA RESULTS




A 14-Month Randomized Clinical Trial of Treatment Strategies for Attention-Deficit/Hyperactivity Disorder. The MTA Cooperative Group
                                                                                                                                17
ARCH GEN PSYCHIATRY/VOL 56, DEC 1999
MTA Study: Conclusions
•   Combined treatment and medication management were more
    effective than behavioral treatment and community care in
    reducing ADHD core symptoms:
      Inattention
      Hyperactive-impulsive behavior
•   Patients in the combined treatment group experienced:
     1. No significant difference in core ADHD symptoms vs. those in
        the medication management group
     2. Improvements in core ADHD symptoms at a lower dose than
        patients in the medication management group
     3. Modest advantages in non-ADHD symptoms and positive
        functioning outcomes vs. patients in the medication
        management group

                   MTA Cooperative Group. Arch Gen Psych. 1999;56:1073-86.
                                                                             18
Medication Selection Considerations
•   Earlier medication response
•   Desired duration of action
•   Patient and parent preference of medication
•   Age of patient
•   Side effect profile
•   Efficacy of response
•   Cost


Canadian Attention Deficit Hyperactivity Disorder Resource Alliance (CADDRA): Canadian ADHD Practice Guidelines, First Edition.
                                                   Toronto, ON; CADDRA, 2006.                                                     19
Plasma Levels and Therapeutic Effect




                t½




                                       20
Concerta – OROS*




*Osmotic-controlled Release Oral delivery System

                                                   21
Concerta and Ritalin Plasma Levels




                                     22
Biphentin (similar for Adderall XR)




                                      23
Vyvanse, Adderall XR: Numbers Test




                                     24
ADHD Therapeutic Options
                                             Two Main
                                        Classes of Medication



           Stimulant                                                                      Non-stimulant

    Methylphenidate
    • Ritalin®                                                                                Atomoxetine
    • Concerta®                                                                               • Strattera®
    • Biphentin®

    Amphetamines
    • Dexedrine® Spansule
    • Adderall® XR
    • Vyvanse ®
Canadian Attention Deficit Hyperactivity Disorder Resource Alliance (CADDRA): Canadian ADHD Practice Guidelines, First Edition.
                                                   Toronto, ON; CADDRA, 2006.                                                     25
Mechanism of Action of ADHD
Medications
   Stimulant                                 Atomoxetine


                           Norepinephrine
Presynaptic neuron                          Presynaptic neuron
                           Dopamine


                           Norepinephrine
                           reuptake pump


                           Dopamine
                           reuptake pump


                      STM Stimulant


                      A    Atomoxetine




Postsynaptic neuron                         Postsynaptic neuron



                                                                  26
1st Line Medications for ADHD Simple
             (Children)
                             FIRST LINE AGENTS – Long-acting preparations
Brand Name                 Dosage                 Starting  Titration Schedule Every 7                    Maximum daily
(Generic)                  Form                   Dose      days*                                         (up to 40 kg child)
                                                            Product           CADDRA                      Product      CADDRA
                                                            Monograph         Board                       Monograph Board
Adderall® XR               5, 10, 15, 20,         10 mg qam ↑5 -10mg         ↑5 -10mg                     30 mg         30 mg
(amphetamine mixed         25, 30 mg cap
salts)
Concerta®             18, 27, 36, 54              18 mg qam ↑18 mg                       ↑18 mg           54 mg              72 mg
(methylphenidate HCl) mg tab
Strattera® *               10, 18, 25, 40,        0.5             0.8 mg/kg/d at wk 3         Same        Lesser of 1.4 mg/kg
(atomoxetine HCl)          60 mg cap              mg/kg/d         1.2 mg/kg/d at wk 5         Same        /day or 60 mg/day
Biphentin®            10, 15, 20, 30,             10-20 mg        ↑ 10 mg                ↑ 10 mg          60 mg              60 mg
(methylphenidate HCl) 40, 50, 60 mg               qam
                      cap
Vyvanse ®             20, 30, 40, 50,             20-30 mg        By clinical             ↑ 10 mg         60 mg              60 mg
(lisdexamfetamine     60                          qam             discretion
Dimesylate)           mg tab

   *atomoxetine every 10 days; clinicians may opt to titrate every 14 days (practicality)

          Canadian Attention Deficit Hyperactivity Disorder Resource Alliance (CADDRA): Canadian ADHD Practice Guidelines,
                                               Third Edition. Toronto, ON; CADDRA, 2011.                                             27
2nd Line / Adjunctive Medications for
                          ADHD Simple (Children)
   SECOND LINE/ADJUNCTIVE AGENTS – Short-acting & moderate-acting preparations
Brand Name                 Dosage            Starting            Titration Schedule              Maximum daily (up to
(Generic)                  Form              Dose                Every 7 days                    40 kg child) CADDRA
Dexedrine®                 5 mg tab          2.5 – 5 mg q  ↑2.5 -5 mg                            40 mg                  20 mg
(dextro-amphetamine                          am and q noon (add q4pm dose)
sulphate)

Dexedrine® Spansule* 10, 15 mg               10 mg q am          ↑10 mg                          40 mg                  30 mg
(dextro-amphetamine cap
sulphate)

PMS® or Ratio® -           5, 10, 20 mg      5 mg q am and ↑5 mg                                 60 mg                  60 mg
methylphenidate            tab               q noon        (add q4pm dose)
Ritalin®              10, 20 mg tab 5 mg b.i.d. to               ↑5 - 10 mg                      60 mg                  60 mg
(methylphenidate HCl)               t.i.d.                       (add q4pm dose)
Ritalin® SR†          20 mg tab              20 mg q am          ↑20 mg                          60 mg                  60 mg
(methylphenidate HCl)                                            (add p2pm dose)

*Dexedrine® Spansule may last 6-8 hours
†Ritalin® SR may help cover the noon period but clinical experience suggests an effect similar to short-acting preparations



 Canadian Attention Deficit Hyperactivity Disorder Resource Alliance (CADDRA): Canadian ADHD Practice Guidelines, Third Edition.
                                                    Toronto, ON; CADDRA, 2011.                                                     28
3rd Line Medications for ADHD Simple
          (Children)

   THIRD LINE AGENTS - Off-label treatments for ADHD used in treatment failure



                                                                        Titration                     Maximum daily
Brand Name                  Dosage                Starting              Schedule                      (up to 40 kg
(Generic)                   Form                  Dose                  Every 7 days                  child)
Apo®-imipramine*            10, 25, 50, 75        25 mg                 ↑25 mg                        150 mg
                            mg tab


Wellbutrin® SR              100, 150 mg           100 mg qam            Add 100 mg qhs                200 mg
(bupropion)                 tab


*Tofranil is not recommended due to inadequate dose forms. Sometimes imipramine is used if mood problems and
ADHD symptoms coexist. Imipramine is metabolized to desipramine which is an effective noradrenergic agonist.




Canadian Attention Deficit Hyperactivity Disorder Resource Alliance (CADDRA): Canadian ADHD Practice Guidelines, First Edition.
                                                   Toronto, ON; CADDRA, 2006.                                                     29
Benefits
• Attention Span
   Reduced distractibility, improved concentration
   Improved organizational skills
• Activity levels
   Reduced restlessness, fidgeting, hyperactivity
• Impulse control
   Improved patience
   Reduced verbal and physical impulsive actions
   Reduced frequency and intensity of emotional
    reactivity                                        30
Adverse Effects
•   Reduced appetite, potential weight loss
•   Insomnia, difficulty to awaken in a.m., cycle
•   Stomach aches
•   Irritability
•   Rebound; wear off of meds
•   Less talkative, stares, ‗zombie‘
•   Tics
•   Skin picking

                                                    31
Diagnosis and Monitoring
The SNAP-IV Short Rating Scale
For each item, check the column that best describes this child:            Not At   Just A   Quite   Very
                                                                           All      Little   A Bit   Much
1. Often fails to give close attention to details or makes careless
   mistakes in schoolwork or tasks                                          ____     ____    ____     ____
2. Often has difficulty sustaining attention in tasks or play activities    ____     ____    ____     ____
3. Often does not seem to listen when spoken to directly                    ____     ____    ____     ____
4. Often does not follow through on instructions and fails to finish
   schoolwork, chores, or duties                                            ____     ____    ____     ____
5. Often has difficulty organizing tasks and activities                     ____     ____    ____     ____
6. Often avoids, dislikes, or reluctantly engages in tasks requiring
   sustained mental effort                                                  ____     ____    ____     ____
7. Often loses things necessary for activities (e.g. toys, school
   assignments, pencils, or books)                                          ____     ____    ____     ____
8. Often is distracted by extraneous stimuli                                ____     ____    ____     ____
9. Often is forgetful in daily activities




                                                                                                             32
Diagnosis and Monitoring
For each item, check the column that best describes this child:         Not At    Just A   Quite   Very
                                                                        All       Little   A Bit   Much

10. Often fidgets with hands or feet or squirms in seat                   ____     ____    ____     ____
11. Often leaves seat in classroom or in other situations in which
    remaining seated is expected                                          ____     ____    ____     ____
12. Often runs about or climbs excessively in situations in which
    it is inappropriate                                                   ____     ____    ____     ____
13. Often has difficulty playing or engaging in leisure activities quietly ____    ____    ____     ____
14. Often is ―on the go‖ or often acts as if ―driven by a motor‖          ____     ____    ____     ____
15. Often talks excessively                                               ____     ____    ____     ____
16. Often blurts out answers before questions have been completed ____             ____    ____     ____
17. Often has difficulty awaiting turn                                    ____     ____    ____     ____
18. Often interrupts or intrudes on other (e.g. butts into conversations/
    games)                                                                ____     ____    ____     ____




                                                                                                           33
Scoring
The 4-point response is scored 0 – 3 (Not at All= 0, Just A Little = 1, Quite A Bit = 2, and Very Much
    = 3). Subscale scores on the SNAP-IV are calculated by summing the scores on the items in the
    specific subset (eg., Inattention) and dividing by the number of items in the subset (eg., 9). The
    score for any subset is expressed as the Average Rating-Per-Item.



Rating Scales II: SNAP scoring                 Tentative 5% cutoffs
                                               Teachers and Parents

ADHD-Inattentive (1-9)           Mean                                 Total
                        T        2.56                                 23
                        P        1.78                                 16
ADHD-Hyperactive/Impulsive (10-18)
                        T        1.78                                 16
                        P        1.44                                 13


                                                                                                         34
School Goal Card – Daily Report




                                  35
Managing Medication Outcomes
                       Therapeutic Response
              Good                                             Poor
• Treat the side effects or                • Reconsider diagnosis or switch to
  reassure & observe if side                 another first line agent
  effects persist                          • If diagnosis is correct, switch to a
• Slightly lower the dose                    second line agent
• Slightly lower the dose &                                                                      High
  supplement with short-acting
  agent                                                                                                         Adverse
• Switch to another first line                                                                                  Effects
  agent
• Continue therapy                         • Reconsider diagnosis
                                           • If diagnosis is correct, raise the
                                             dose or switch to another agent                     Low
                                           • Validate patient adherence


Canadian Attention Deficit Hyperactivity Disorder Resource Alliance (CADDRA): Canadian ADHD Practice Guidelines, First Edition.
                                                   Toronto, ON; CADDRA 2006.                                                      36
Resources
Support Groups
Look for support groups in your area on the CADDAC website (www.caddac.ca)
under Resources.

Websites
Canadian ADHD Resource Alliance (CADDRA) – www.caddra.ca
Centre for ADD/ADHD Advocacy, Canada (CADDAC) – www.caddac.ca
Attention Deficit Disorder Association (ADDA) - www.add.org
Answers to your questions about ADHD (Patricia O. Quinn, MD and Kathleen
Nadeau, PhD) - www.ADDvance.com
Online catalogue of ADHD resources – www.addwarehouse.com
Quebec-based Dr Annick Vincent's ADHD website - www.attentiondeficit-
info.com
Children and Adults with Attention Deficit Hyperactivity Disorder – www.chadd.org
Connecting doctors, parents and teachers – www.myadhd.com
Online planner - www.skoach.com
Totally ADD – www.totallyadd.com

                                                                                    37
GOALS
•   Effectiveness
•   Duration
•   Minimal Adverse Effects
•   Management of Adverse Effects
•   Regular monitoring
•   Individualized schedule
•   Happy well functioning child/ adolescent
•   The ‗Science of effectiveness‘ for teens
•   Personal responsibility for one‘s own ADHD
                                                 38
ADHD Assessment Instruments/Tools

• The following websites contain various types
  of ADHD testing tools:
   www.neurotransmitter.net/adhdscales.html
   www.massgeneral.org/schoolpsychiatry/screenin
    gtools_table.asp
   SNAP-IV: www.adhdcanada.com/pdfs/SNAP-
    IVTeacherParetnRatingScale.pdf
   Weiss Functional Impairment Scale:
    http://www.caddra.ca/english/pdfs/Child_7.pdf


                                                    39
QUESTIONS?




             40
True or False?
1. The best way to arrive at the correct dose of stimulant medication is by
   adjusting it to the weight of the child.

2. Structured classrooms are useful locations for observations about
   ADHD features and responses to medication.

3. Three times daily medication administration is usually best because
   fine adjustments can be made for each dose.




                                                                              41
True or False?
1. The best way to arrive at the correct dose of stimulant medication is by
   adjusting it to the weight of the child.              FALSE

Clinical response of each individual child is the best indicator for adjusting
    medication.

2. Well structured classrooms are useful locations for observations about
   ADHD features and responses to medication.            TRUE

Settings with looser structure allow enough variation in activities that many
   features of ADHD may be far less noticeable.

3. Three times daily medication administration is usually best because
   fine adjustments can be made for each dose.           FALSE

Single long acting doses tend to work more smoothly for the child through
   out the full day and have reduced potential for adverse effects.

                                                                                 42
Oppositional Defiant Disorder
• Review the DSM IV TR
• Primarily an environmentally determined
  disorder
• Major predisposing factor—ADHD
• Can be confused with normal developmental
  stage of development of autonomy—ages 2-3




                                              43
The Non Compliance Cycle
                                                                     Parent
                                                                   commands


                                                                                        Other
                                        Parent                                      interactions
                                        Repeats                    Compliance
                                       command
               Loop repeats
                3 to 7 times


                                      Compliance



                                        Parent
                                       threatens
               Loop repeats
                3 to 7 times

                                     Compliance




                                       Parent
                                                                     Acquiescence
                                         ?




                                     Aggression


Presentation by Barkley R. Original research, by Patterson G (?)
                                                                                                   44
Three Pathways to Boys’ Problem
                          Behaviour and Delinquency.
AGE OF                                                                                                           % BOYS
ONSET
                                                                                                                  Few
 Late

                                                       VIOLENCE       MOD. To
                                                     (rape, attack    SERIOUS
                                                      Strong arm)     DELINQUENCY
                                                                      (fraud, burglary,
                                                                      Serious theft)

                                      PHYSICAL FIGHTING                   PROPERTY DAMAGE
                                       (physical fighting,               (vandalism, fire setting)
                                         Gang fighting)

                                                             AUTHORITY
                                                             AVOIDANCE
                         MINOR AGGRESSION                     (truancy,          MINOR COVERT BEHAVIOR
                       (bullying, annoying others)          Running away,        (shoplifting, frequent lying)
                                                           Staying out late)

                     OVERT PATHWAY                                                             COVERT PATHWAY)
                                                      DEFIANCE/ DISOBEDIENCE

                                                                                                                  Many
 Early
                                                      STUBBORN BEHAVIOUR

                                                 AUTHORITY CONFLICT PATHWAY
                                                        (before age 12)

    Loeber R &Hay. Three developmental pathways to serious disruptive behaviours.
                                                                                                                         45
The Benefits of Treatment? One Study
  •     Retrospective study of 25 adolescents age 15 at a Toronto residential
        setting:
  •     Start of problems:
          Age 4.7 years
          First intervention age 6.48 years
          Average number of CD symptoms: 5
  •     Age 16
          15.6 Agencies
          Average 8 months / agency
          18.9 interventions
          Average 7 months / intervention
          Number of schools – 6.88
          Average number of CD symptoms: 10.16


Shamsie J. Conference on Conduct Disorder, Vancouver BC 1990. Later literatrue noted in following article.
Shamsie J, Hamilton H, Sykes C. Can J Psychiatry 1996; 41:211-216. The Characteristics and Intervention Histories of Incarcerated and Conduct-   46
Disordered Youth
Managing
Disruptive Behavioral Disorders
 1. Program Infrastucture
          Cognitive Behavioral Approach
 2. Assess and Manage
          Token Economy
           Therapeutic Classroom
 3. Skill Building
          Relaxation
           Psycho-educational Anger Management
 4. Classical Therapy (Blind Trials)
          Social Skills
           Medication           Anxiety Management
           Individual
          Activity Based        Unstructured Time
 5. School Preparation ADL/ Recreation
           Occupational/
           Family
           Behavioral Management
 6. Child Computerized (CPT, Dominic)
           Management Training
           Group
           Medication Observation
           Parents – Mandatory
           Report Cards
 7. In the Cooperative Activity
           Teachers .
           Community
           Child- Individual
           SchoolVisits
           Family Anxiety takers
           Home - Social
 8. Case Conferencing Work
           Associated Care
           School Visits
           Parenting Schools
            Community
           Parents & Teachers–
           Individual Parent
            Community Child / 1 way mirror
               Observe Agencies (Health, FCS, Others)
                                                        47
Adapted from: The Discipline Pyramid. From McMahon, Slough, and Conduct Problems Prevention   48
Research Group (1996). Copyright 1996 by Sage Publications, Inc.

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What Teachers Need to Know About ADHD Medications

  • 1. WHAT TEACHERS NEED TO KNOW ABOUT ADHD MEDICATIONS 1
  • 2. CREDITS Attention-Deficit/Hyperactivity Disorder (ADHD) At the Leading Edge Program Directors: Emmett Francoeur, MD, FRCPC Samuel Chang, MD, FRCPC Grazyna Jackiewicz, MD, FRCPC Associate Professor, Clinical Associate Assistant McGill University Professor, University of Calgary Professor, Pediatrics, McMaster Director, Child Development Director, Adolescent Substance University Program, McGill University Abuse & Psychiatric Disorders Clinic Consulting Pediatrician in Health Center Psychiatrist, Foothills Medical Developmental/Behavioural Westmount, Quebec Centre Pediatrics, American Board Certified Calgary, Alberta Chedoke Developmental/ Behavioural Clinic, Hamilton, Ontario Private Practice, Niagara Falls, Ontario
  • 3. ASSUMPTIONS • Co Morbidities • Prevalence • Causes • Symptoms • Assessment 3
  • 4. SOCIETAL IMPORTANCE • Prevalence • Developmental Sequencing • Economics • Multijurisdictional Agency Involvement • Multimodal Management • Prevention 4
  • 5. ADHD is Most Likely Caused by a Complex Interplay of Factors Neuroanatomic Genetic origins Neurochemical ADHD Environmental factors CNS insults Swanson JM, et al. Mol Psychiatry. 1998;3(1):38-41. Swanson JM, et al. Lancet. 1998; 351(9100):429-33. Milberger S, et al. Biol Psychiatry. 1997;41(1):65- 75. Castellanos FX, et al. Arch Gen Psychiatry. 1996;53(7):607-16. 5
  • 6. ADHD Impacts Domains of Function Difficulty With: Before School After School Bedtime School • Waking up • Lower grades • Sports/Clubs • Bedtime prep • Getting ready for • Lack of focus • Homework • Settling down school • Disruptive • Risky behavior and falling asleep • Struggling • Difficulty with and injuries excessively friendships • Sitting through dinner with parents • Family interactions Barkley RA, et al. J Am Acad Child Adolesc Psychiatry. 1990;29(4):546-57. Barkley RA. J Clin Psychiatry. 2002;63(Suppl 12):S10-5. DuPaul GJ, et al. J Am Acad Child Adolesc Psychiatry. 2001;40(5):508-15. Greenhill LL. J Clin Psychiatry. 1998;59(Suppl 7):S31-41. Weiss G, et al. J Am Acad Child Psychiatry 6 1985;24(2):211-20.
  • 7. ADHD Impacts Social Functioning Problems • Problems with the justice system • Family conflicts • Early and impulsive sexuality + ADHD • Tobacco and substance abuse • Accidents and injuries • Interpersonal difficulties • School and professional difficulties American Academy of Pediatrics. Pediatrics. 2000:105(5);1158-70. Barkley RA, et al. Clinical Child and Family Psychology Review. 2002;5(2):89-111. Barkley RA. In: Barkely RA, ed. Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment, Third Edition. New York; Guilford, 7 2006.
  • 8. Evidence for Frontal Lobe Deficits •Deficits on Executive Function Tests •Less Frontal Electrical Activity (QEEG, EEG, EP) •Reduced Blood Flow to Frontal and Striatal Regions (SPECT; Altropane Uptake) •Diminished Frontal and Striatal Metabolic Activity (PET and fMRI) •Smaller Frontal-Basal Ganglia-Cerebellar Areas (MRI) 8
  • 9. Development and Progressive Cortical Cell Density 9
  • 10. Executive Functions Often Impaired in ADHD Executive Functions Organizing Focusing, Regulating Managing Utilizing Monitoring prioritizing, sustaining alertness, frustration working and self- and focus, and sustaining And memory regulating activating shifting effort, and modulating And action to work focus to processing emotions accessing tasks speed recall 1. 2. 3. 4. 5. 6. Activation Focus Effort Emotion Memory Action Brown TE. 2001. Manual for Attention Deficit Disorder Scales for Children and Adolescents. 10
  • 11. Clinical Presentation of ADHD in Adolescents ADHD Symptoms in Adolescents May have a sense of inner Procrastinates and displays restlessness rather than hyperactivity disorganized school work with poor follow-through Fails to work independently Poor peer relationships Poor self-esteem Inability to delay gratification Specific learning disabilities Behaviour not usually modified by Engages in ―risky‖ behaviour reward or punishment (speeding, unprotected sex, substance abuse) Apparent disregard for own safety Difficulties or clashes with authority (injuries and accidents) Greenhill LL. J Clin Psych. 1998;59(Suppl 7):31-41. 11
  • 12. Persistance of Disorder •Symptoms decrease somewhat with age •Adolescence: (Based on Parent reports) •50% persistence to adolescence (1970-80s) •70-80% in modern DSM studies (1990s onward) •Young Adulthood (age 20-26) (Barkley et al. 2002) •Depends on who you ask (self vs. parents) •3-8% Full disorder (self-report using DSM III R •46% Full disorder (parent reports using DSM III R) •12% - Using 98th percentile (+2SDs; self-report) •66% - Using 98th percentile (parent report) •Parent reports have greater veracity—they correlate more highly with various domains of major life activities than do self reports •85-90% remain functionally impaired Barkley RA. 2003. Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment 12
  • 13. Role of teachers • Observer • Reporter (report cards) • Manager • Parent liaison • Health Care liaison • Monitor 13
  • 14. ADHD Management Goals • Treat ADHD throughout the lifespan • Treat symptoms throughout the full day in multiple areas of a patient‘s daily life  No longer sufficient to treat during the school day or work hours • Develop collaboration between home and school Connor DF. In: Barkley RA, ed. Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment, Third Edition. New York; Guilford, 2006. Canadian Attention Deficit Hyperactivity Disorder Resource Alliance (CADDRA): Canadian ADHD Practice 14 Guidelines, First Edition. Toronto, ON; CADDRA, 2006.
  • 15. ADHD Management Strategies • Psychoeducation  Give local resources, written material and web based resources • Psychosocial interventions  Classroom intervention, family counselling, support groups • Medications  Mainstay of treatment, single most effective intervention, safe, effective and non addictive  Not for children less than 6 years old (certain exceptions apply) Canadian Attention Deficit Hyperactivity Disorder Resource Alliance (CADDRA): Canadian ADHD Practice Guidelines, First Edition. Toronto, ON; CADDRA, 2006. 15
  • 16. MTA Study: Objective and Design Objective: To compare the long-term efficacy of pharmacotherapy, behavioral therapy, and combination therapy in the treatment of ADHD. Medication management (primarily methylphenidate) 579 Children ADHD, Combined type Age Range: 7-9.9 years Behavioral treatment Randomly assigned 14-month study Combination treatment: medication and behavioral therapy Routine Community Care MTA Cooperative Group. Arch Gen Psych. 1999;56:1073-1086. 16
  • 17. MTA RESULTS A 14-Month Randomized Clinical Trial of Treatment Strategies for Attention-Deficit/Hyperactivity Disorder. The MTA Cooperative Group 17 ARCH GEN PSYCHIATRY/VOL 56, DEC 1999
  • 18. MTA Study: Conclusions • Combined treatment and medication management were more effective than behavioral treatment and community care in reducing ADHD core symptoms:  Inattention  Hyperactive-impulsive behavior • Patients in the combined treatment group experienced: 1. No significant difference in core ADHD symptoms vs. those in the medication management group 2. Improvements in core ADHD symptoms at a lower dose than patients in the medication management group 3. Modest advantages in non-ADHD symptoms and positive functioning outcomes vs. patients in the medication management group MTA Cooperative Group. Arch Gen Psych. 1999;56:1073-86. 18
  • 19. Medication Selection Considerations • Earlier medication response • Desired duration of action • Patient and parent preference of medication • Age of patient • Side effect profile • Efficacy of response • Cost Canadian Attention Deficit Hyperactivity Disorder Resource Alliance (CADDRA): Canadian ADHD Practice Guidelines, First Edition. Toronto, ON; CADDRA, 2006. 19
  • 20. Plasma Levels and Therapeutic Effect t½ 20
  • 21. Concerta – OROS* *Osmotic-controlled Release Oral delivery System 21
  • 22. Concerta and Ritalin Plasma Levels 22
  • 23. Biphentin (similar for Adderall XR) 23
  • 24. Vyvanse, Adderall XR: Numbers Test 24
  • 25. ADHD Therapeutic Options Two Main Classes of Medication Stimulant Non-stimulant Methylphenidate • Ritalin® Atomoxetine • Concerta® • Strattera® • Biphentin® Amphetamines • Dexedrine® Spansule • Adderall® XR • Vyvanse ® Canadian Attention Deficit Hyperactivity Disorder Resource Alliance (CADDRA): Canadian ADHD Practice Guidelines, First Edition. Toronto, ON; CADDRA, 2006. 25
  • 26. Mechanism of Action of ADHD Medications Stimulant Atomoxetine Norepinephrine Presynaptic neuron Presynaptic neuron Dopamine Norepinephrine reuptake pump Dopamine reuptake pump STM Stimulant A Atomoxetine Postsynaptic neuron Postsynaptic neuron 26
  • 27. 1st Line Medications for ADHD Simple (Children) FIRST LINE AGENTS – Long-acting preparations Brand Name Dosage Starting Titration Schedule Every 7 Maximum daily (Generic) Form Dose days* (up to 40 kg child) Product CADDRA Product CADDRA Monograph Board Monograph Board Adderall® XR 5, 10, 15, 20, 10 mg qam ↑5 -10mg ↑5 -10mg 30 mg 30 mg (amphetamine mixed 25, 30 mg cap salts) Concerta® 18, 27, 36, 54 18 mg qam ↑18 mg ↑18 mg 54 mg 72 mg (methylphenidate HCl) mg tab Strattera® * 10, 18, 25, 40, 0.5 0.8 mg/kg/d at wk 3 Same Lesser of 1.4 mg/kg (atomoxetine HCl) 60 mg cap mg/kg/d 1.2 mg/kg/d at wk 5 Same /day or 60 mg/day Biphentin® 10, 15, 20, 30, 10-20 mg ↑ 10 mg ↑ 10 mg 60 mg 60 mg (methylphenidate HCl) 40, 50, 60 mg qam cap Vyvanse ® 20, 30, 40, 50, 20-30 mg By clinical ↑ 10 mg 60 mg 60 mg (lisdexamfetamine 60 qam discretion Dimesylate) mg tab *atomoxetine every 10 days; clinicians may opt to titrate every 14 days (practicality) Canadian Attention Deficit Hyperactivity Disorder Resource Alliance (CADDRA): Canadian ADHD Practice Guidelines, Third Edition. Toronto, ON; CADDRA, 2011. 27
  • 28. 2nd Line / Adjunctive Medications for ADHD Simple (Children) SECOND LINE/ADJUNCTIVE AGENTS – Short-acting & moderate-acting preparations Brand Name Dosage Starting Titration Schedule Maximum daily (up to (Generic) Form Dose Every 7 days 40 kg child) CADDRA Dexedrine® 5 mg tab 2.5 – 5 mg q ↑2.5 -5 mg 40 mg 20 mg (dextro-amphetamine am and q noon (add q4pm dose) sulphate) Dexedrine® Spansule* 10, 15 mg 10 mg q am ↑10 mg 40 mg 30 mg (dextro-amphetamine cap sulphate) PMS® or Ratio® - 5, 10, 20 mg 5 mg q am and ↑5 mg 60 mg 60 mg methylphenidate tab q noon (add q4pm dose) Ritalin® 10, 20 mg tab 5 mg b.i.d. to ↑5 - 10 mg 60 mg 60 mg (methylphenidate HCl) t.i.d. (add q4pm dose) Ritalin® SR† 20 mg tab 20 mg q am ↑20 mg 60 mg 60 mg (methylphenidate HCl) (add p2pm dose) *Dexedrine® Spansule may last 6-8 hours †Ritalin® SR may help cover the noon period but clinical experience suggests an effect similar to short-acting preparations Canadian Attention Deficit Hyperactivity Disorder Resource Alliance (CADDRA): Canadian ADHD Practice Guidelines, Third Edition. Toronto, ON; CADDRA, 2011. 28
  • 29. 3rd Line Medications for ADHD Simple (Children) THIRD LINE AGENTS - Off-label treatments for ADHD used in treatment failure Titration Maximum daily Brand Name Dosage Starting Schedule (up to 40 kg (Generic) Form Dose Every 7 days child) Apo®-imipramine* 10, 25, 50, 75 25 mg ↑25 mg 150 mg mg tab Wellbutrin® SR 100, 150 mg 100 mg qam Add 100 mg qhs 200 mg (bupropion) tab *Tofranil is not recommended due to inadequate dose forms. Sometimes imipramine is used if mood problems and ADHD symptoms coexist. Imipramine is metabolized to desipramine which is an effective noradrenergic agonist. Canadian Attention Deficit Hyperactivity Disorder Resource Alliance (CADDRA): Canadian ADHD Practice Guidelines, First Edition. Toronto, ON; CADDRA, 2006. 29
  • 30. Benefits • Attention Span  Reduced distractibility, improved concentration  Improved organizational skills • Activity levels  Reduced restlessness, fidgeting, hyperactivity • Impulse control  Improved patience  Reduced verbal and physical impulsive actions  Reduced frequency and intensity of emotional reactivity 30
  • 31. Adverse Effects • Reduced appetite, potential weight loss • Insomnia, difficulty to awaken in a.m., cycle • Stomach aches • Irritability • Rebound; wear off of meds • Less talkative, stares, ‗zombie‘ • Tics • Skin picking 31
  • 32. Diagnosis and Monitoring The SNAP-IV Short Rating Scale For each item, check the column that best describes this child: Not At Just A Quite Very All Little A Bit Much 1. Often fails to give close attention to details or makes careless mistakes in schoolwork or tasks ____ ____ ____ ____ 2. Often has difficulty sustaining attention in tasks or play activities ____ ____ ____ ____ 3. Often does not seem to listen when spoken to directly ____ ____ ____ ____ 4. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties ____ ____ ____ ____ 5. Often has difficulty organizing tasks and activities ____ ____ ____ ____ 6. Often avoids, dislikes, or reluctantly engages in tasks requiring sustained mental effort ____ ____ ____ ____ 7. Often loses things necessary for activities (e.g. toys, school assignments, pencils, or books) ____ ____ ____ ____ 8. Often is distracted by extraneous stimuli ____ ____ ____ ____ 9. Often is forgetful in daily activities 32
  • 33. Diagnosis and Monitoring For each item, check the column that best describes this child: Not At Just A Quite Very All Little A Bit Much 10. Often fidgets with hands or feet or squirms in seat ____ ____ ____ ____ 11. Often leaves seat in classroom or in other situations in which remaining seated is expected ____ ____ ____ ____ 12. Often runs about or climbs excessively in situations in which it is inappropriate ____ ____ ____ ____ 13. Often has difficulty playing or engaging in leisure activities quietly ____ ____ ____ ____ 14. Often is ―on the go‖ or often acts as if ―driven by a motor‖ ____ ____ ____ ____ 15. Often talks excessively ____ ____ ____ ____ 16. Often blurts out answers before questions have been completed ____ ____ ____ ____ 17. Often has difficulty awaiting turn ____ ____ ____ ____ 18. Often interrupts or intrudes on other (e.g. butts into conversations/ games) ____ ____ ____ ____ 33
  • 34. Scoring The 4-point response is scored 0 – 3 (Not at All= 0, Just A Little = 1, Quite A Bit = 2, and Very Much = 3). Subscale scores on the SNAP-IV are calculated by summing the scores on the items in the specific subset (eg., Inattention) and dividing by the number of items in the subset (eg., 9). The score for any subset is expressed as the Average Rating-Per-Item. Rating Scales II: SNAP scoring Tentative 5% cutoffs Teachers and Parents ADHD-Inattentive (1-9) Mean Total T 2.56 23 P 1.78 16 ADHD-Hyperactive/Impulsive (10-18) T 1.78 16 P 1.44 13 34
  • 35. School Goal Card – Daily Report 35
  • 36. Managing Medication Outcomes Therapeutic Response Good Poor • Treat the side effects or • Reconsider diagnosis or switch to reassure & observe if side another first line agent effects persist • If diagnosis is correct, switch to a • Slightly lower the dose second line agent • Slightly lower the dose & High supplement with short-acting agent Adverse • Switch to another first line Effects agent • Continue therapy • Reconsider diagnosis • If diagnosis is correct, raise the dose or switch to another agent Low • Validate patient adherence Canadian Attention Deficit Hyperactivity Disorder Resource Alliance (CADDRA): Canadian ADHD Practice Guidelines, First Edition. Toronto, ON; CADDRA 2006. 36
  • 37. Resources Support Groups Look for support groups in your area on the CADDAC website (www.caddac.ca) under Resources. Websites Canadian ADHD Resource Alliance (CADDRA) – www.caddra.ca Centre for ADD/ADHD Advocacy, Canada (CADDAC) – www.caddac.ca Attention Deficit Disorder Association (ADDA) - www.add.org Answers to your questions about ADHD (Patricia O. Quinn, MD and Kathleen Nadeau, PhD) - www.ADDvance.com Online catalogue of ADHD resources – www.addwarehouse.com Quebec-based Dr Annick Vincent's ADHD website - www.attentiondeficit- info.com Children and Adults with Attention Deficit Hyperactivity Disorder – www.chadd.org Connecting doctors, parents and teachers – www.myadhd.com Online planner - www.skoach.com Totally ADD – www.totallyadd.com 37
  • 38. GOALS • Effectiveness • Duration • Minimal Adverse Effects • Management of Adverse Effects • Regular monitoring • Individualized schedule • Happy well functioning child/ adolescent • The ‗Science of effectiveness‘ for teens • Personal responsibility for one‘s own ADHD 38
  • 39. ADHD Assessment Instruments/Tools • The following websites contain various types of ADHD testing tools:  www.neurotransmitter.net/adhdscales.html  www.massgeneral.org/schoolpsychiatry/screenin gtools_table.asp  SNAP-IV: www.adhdcanada.com/pdfs/SNAP- IVTeacherParetnRatingScale.pdf  Weiss Functional Impairment Scale: http://www.caddra.ca/english/pdfs/Child_7.pdf 39
  • 41. True or False? 1. The best way to arrive at the correct dose of stimulant medication is by adjusting it to the weight of the child. 2. Structured classrooms are useful locations for observations about ADHD features and responses to medication. 3. Three times daily medication administration is usually best because fine adjustments can be made for each dose. 41
  • 42. True or False? 1. The best way to arrive at the correct dose of stimulant medication is by adjusting it to the weight of the child. FALSE Clinical response of each individual child is the best indicator for adjusting medication. 2. Well structured classrooms are useful locations for observations about ADHD features and responses to medication. TRUE Settings with looser structure allow enough variation in activities that many features of ADHD may be far less noticeable. 3. Three times daily medication administration is usually best because fine adjustments can be made for each dose. FALSE Single long acting doses tend to work more smoothly for the child through out the full day and have reduced potential for adverse effects. 42
  • 43. Oppositional Defiant Disorder • Review the DSM IV TR • Primarily an environmentally determined disorder • Major predisposing factor—ADHD • Can be confused with normal developmental stage of development of autonomy—ages 2-3 43
  • 44. The Non Compliance Cycle Parent commands Other Parent interactions Repeats Compliance command Loop repeats 3 to 7 times Compliance Parent threatens Loop repeats 3 to 7 times Compliance Parent Acquiescence ? Aggression Presentation by Barkley R. Original research, by Patterson G (?) 44
  • 45. Three Pathways to Boys’ Problem Behaviour and Delinquency. AGE OF % BOYS ONSET Few Late VIOLENCE MOD. To (rape, attack SERIOUS Strong arm) DELINQUENCY (fraud, burglary, Serious theft) PHYSICAL FIGHTING PROPERTY DAMAGE (physical fighting, (vandalism, fire setting) Gang fighting) AUTHORITY AVOIDANCE MINOR AGGRESSION (truancy, MINOR COVERT BEHAVIOR (bullying, annoying others) Running away, (shoplifting, frequent lying) Staying out late) OVERT PATHWAY COVERT PATHWAY) DEFIANCE/ DISOBEDIENCE Many Early STUBBORN BEHAVIOUR AUTHORITY CONFLICT PATHWAY (before age 12) Loeber R &Hay. Three developmental pathways to serious disruptive behaviours. 45
  • 46. The Benefits of Treatment? One Study • Retrospective study of 25 adolescents age 15 at a Toronto residential setting: • Start of problems:  Age 4.7 years  First intervention age 6.48 years  Average number of CD symptoms: 5 • Age 16  15.6 Agencies  Average 8 months / agency  18.9 interventions  Average 7 months / intervention  Number of schools – 6.88  Average number of CD symptoms: 10.16 Shamsie J. Conference on Conduct Disorder, Vancouver BC 1990. Later literatrue noted in following article. Shamsie J, Hamilton H, Sykes C. Can J Psychiatry 1996; 41:211-216. The Characteristics and Intervention Histories of Incarcerated and Conduct- 46 Disordered Youth
  • 47. Managing Disruptive Behavioral Disorders 1. Program Infrastucture Cognitive Behavioral Approach 2. Assess and Manage Token Economy Therapeutic Classroom 3. Skill Building Relaxation Psycho-educational Anger Management 4. Classical Therapy (Blind Trials) Social Skills Medication Anxiety Management Individual Activity Based Unstructured Time 5. School Preparation ADL/ Recreation Occupational/ Family Behavioral Management 6. Child Computerized (CPT, Dominic) Management Training Group Medication Observation Parents – Mandatory Report Cards 7. In the Cooperative Activity Teachers . Community Child- Individual SchoolVisits Family Anxiety takers Home - Social 8. Case Conferencing Work Associated Care School Visits Parenting Schools Community Parents & Teachers– Individual Parent Community Child / 1 way mirror Observe Agencies (Health, FCS, Others) 47
  • 48. Adapted from: The Discipline Pyramid. From McMahon, Slough, and Conduct Problems Prevention 48 Research Group (1996). Copyright 1996 by Sage Publications, Inc.

Notas do Editor

  1. QEEG - Quantitative ElectroencephalographyEP - Evoked PotentialsSPECT – Single Photon Emission Computed TomographyMRI - Magnetic Resonance ImagingAltropane – small molecule that binds with extremely high affinity and specificity to dopamine transporters