Adhd proiect

8/12/2019 Adhd proiect

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ADHD Through The Life Cycle

by

Humberto Nagera M.D.

Professor of Psychiatry, University of SouthFlorida.

Professor Emeritus, University of Michigan.

Training and Supervising Psychoanalyst,Tampa Bay Psychoanalytic Institute.

Director, The Carter-Jenkins Center.


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ADHD Through The Life Cycle:

Myths About ADHD

1) Only affects children

2) Disappears in adolescence

3) Does not affect adults

4) Ritalin has paradoxical effects in

children not in adults


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History of the Disorder

First called minimal brain damage

Afterwards called minimal brain dysfunction

Next called ADD

Finally called ADHD


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Etiology of the Disorder

ADHD is a genetic disorder

Involves possibly several genes

They have a tendency to segregate together

This may mean they are close to one another


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Etiology of the Disorder

Runs in families

Manifests itself with different degrees ofseverity in a given generation

Manifest itself with different degrees ofseverity in each one of the various generations


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Some General Characteristics

Some have learning disabilities (5-10%)

Some have soft neurological signs

Watch for Tourettes disorder

1 or 2% may be co-morbid with BD

As they grow older can become ODD, CD etc


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Some General Characteristics

Lack of social skills, unpopular, need to be first

Needs are imperative, now, can not wait

Lower threshold for stimuli (ADHD a misnomer)

Writing a problem, reversal of letters etc


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Symptoms In Children

Distractability, inability to pay attention

Hyperactivity (more in boys than girls)

Impulsivity (doing things without thinking of

the consequences)

I will add irritability (very short fuses)


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ADHD Through The Life Cycle Adult

Characteristics

1) ADHD persist into adulthood 75% of the time

2) Up to 4% of adults suffer from it

3) It can be quite crippling, according toseverity of the disorder


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Adult Characteristics

4) Diagnosis similar to that in children but:

a) At times hyperactivity is better controlled

b) In adults nearly as many females as males


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c) Early conflicts at school are the same but

with a change of scenarios. School

becomes the workplace, peers-spouses,teacher-bosses etc

5) Treatment is similar to that of children


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6) Watch for alcohol and or drug abuse

(common)

7) Watch for substance abusers:

a) Interview wife

b) Call their physician, pastor etcc) Offer Desipramine


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Symptoms Of Adults

1) Distractability in different degrees

2) Hyperactivity present but better controlsometimes

3) Impulsivity (acting without thinking)

4) Irritability, hot temper, affective lability

5) Significant stress intolerance


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Drugs Used For Treatment

WARNING:Do not use Cylert as first line

Drugs most used are var ious forms of:

a) Ritalin(methylphenidate)(Various forms, Concerta)

b) Dextro-amphetamines(Various forms)

c) Tricyclicsand/or antihipertensives

d) Wellbutrin, Clonidine, neuroleptics etc

e) Monoamine oxidase inhibitors(effective but very

dangerous, particularly in children)

f) Focalinand Ritalin La

g)Atomoxetine(Strattera)



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Ritalin is classif ied as a psychostimulant drug

Comes in several forms:

a) Straight Ritalin (5, 10, and 15 mg) (3 H)

b) SR Ritalin (Ciba 20 mg) (not recommended)

c) Metadate CD, ER, (Celltech 20 mg) (5-6 H)

d) Concerta(ER) (18, 27, 36 and 54 mg) ( 11- 12 H)

e) FocalinTM (2.5, 5, 10 mg) (Out recently)

f) Ritalin LA (20, 30, 40 mg) ( 7 hours ?)(Sprinkle)


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Dextro-amphetamines:

1) Most used straight release are:

a) Dexedrine (5mg), (4 H)

b) Dextrostat (5 and 10 mg) (4 H)

c) Adderall (5, 10, 20 mg) (4 H)

2) Slow releases:a) Dexedrine SR (5, 10 and 15 mg) (7-10 H)

b) Adderall XR (10, 20 and 30 mg capsules) (7-10 H)

ADHD Th h Th Lif C l


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Tricyclic antidepressants:

1) Longer duration of action (once daily dosing)

2) No rebound or insomnia problems

3) Can monitor plasma drug levels (for safety and

compliance)

4) No risk of abuse, small doses of 10-25 mg

5) Some death reports in children with TCAs

(next)

T i li A tid t ( t)


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Tricyclic Antidepressants (cont) Those more frequently used in the pastwere:

a) Norpramin (imipramine+desipramine)

-Dirty, many side effects

b) Better to use Desipramine (less sideeffects, may respond by third day)

c) Nortriptiline (not generally used)

Always monitor cardiovascular side effects



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The Use of Catapres (Clonidine), and Tenex:

1) Clonidine is an imidazoline derivative usedas antihypertensive agent

2) Reduce the activation or arousal of ADHD,Tourettes syndrome and aggression

3) Used in highly irritable, impulsive andaggressive children (next)



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4) On occasion Clonidine is given with Ritalinor Dexedrine with optimal results

5) Useful in motor tics, overactive ADHD, growth

impairment

6) Not useful to control distractability itself

7) Helps sleep if taken in late afternoon

(next)



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ADHD Through The Life CycleDrugs Used For Treatment

8) Can be taken up to 3x q.d ( 6 hours interval) at

doses of up to 0.1 mg (total of 0.3-0.3 mg)

9) Major side effect is sedation starting 30-60 after

doses is taken

10) Excretion half life 8-12 H but very variable

11) May take 2 - 4 weeks to see response

(beyond sedation) (next)



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12) Patches can be used delivering 0.1-0.3 mgq.d for a week according to size of patch

13) Guanfacine (Tenex) can be given in dosesof 1-3 mg q.d (6 hours interval between

doses)

14) Guanfacine (Tenex) has the same

indications of Clonidine

N D h M k


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New Drug on the Market

Atomoxetine (Strattera) is a re-uptake inhibitor ofnorepinephrine . It is not a psychostimulant.

Best doses seems to be 1.2 mg/kg/day

Now approved. Limited experience with it. Does not

exacerbate tics. Covers patient 24 hours. No safety

concerns as with tricyclics. Not controlled by FDA

Side effects: Decreased appetite, nausea, loss of weight,

somnolence, etc. Loss of libido (7%). Non-addictive.


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The End

Questions?


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God Bless America

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