ADHD

Jeffrey Barratt, MD
 Diagnosis/Criteria

▶ 6 symptoms prior to age 12 occurring in 2 or more settings

▶ Difficulty paying attention, excessive activity, and impulsivity
▶ Screwing up your life
▶ Have parent and teacher give data in addition to your interview (because it is
best gauged by comparing against a norm)
ADHD predominantly inattentive
presentation

▶ Fails to give close attention to details or makes careless mistakes

▶ Has difficulty sustaining attention
▶ Does not appear to listen
▶ Struggles to follow through with instructions
▶ Has difficulty with organization
▶ Avoids or dislikes tasks requiring sustained mental effort 
▶ Loses things
▶ Is easily distracted
▶ Is forgetful in daily activities 
ADHD predominantly hyperactive-
impulsive presentation
▶ Fidgets with hands or feet or squirms in chair 
▶ Has difficulty remaining seated 
▶ Runs about or climbs excessively in children; extreme restlessness in adults
▶ Difficulty engaging in activities quietly 
▶ Acts as if driven by a motor; adults will often feel inside as if they are driven
by a motor
▶ Talks excessively 
▶ Blurts out answers before questions have been completed 
▶ Difficulty waiting or taking turns 
▶ Interrupts or intrudes upon others 
ADHD combined presentation

▶ The individual meets the criteria for both inattention and hyperactive-
impulsive ADHD presentations.
▶  https://www.youtube.com/watch?v=yRYl9Bf0yhs
▶ Watch the segments in the above video: 0-1:30, 5:40-7:30, 41-42:30
Prescreening
▶ AAPediatrics: do a cardiovascular-focused patient history, family history, and physical
examination. If the history and examination are not suggestive of cardiac disease, ADHD
pharmacotherapy can be started
▶ Routine EKG is not recommended, as the incidence of sudden cardiac death is similar to
general peds population. There are no specific ECG findings associated with an increased
likelihood of a serious cardiac adverse event due to ADHD therapy
▶ Patient history of cardiac disease, rheumatic fever, fainting or dizziness especially with
exercise, chest pain or shortness of breath with exercise, palpitations, high blood pressure,
and heart murmur.
▶ Family history of sudden or unexplained death or event in child/young adult, cardiac
arrhythmias (eg, WPW), long QT syndrome, catecholaminergic paroxysmal ventricular
tachycardia, Brugada syndrome, arrhythmogenic right ventricular dysplasia, hypertrophic
cardiomyopathy, dilated cardiomyopathy, and Marfan syndrome. 
▶ The child's baseline height, weight, blood pressure, and heart rate should be measured.
▶ A pretreatment baseline should be established for common side effects associated with
pharmacotherapy for ADHD (e.g., appetite, sleep pattern, headaches, abdominal pain).
▶ Adolescent patients should be assessed for substance use or abuse.
What to use

Therapy Medication
▶ Behavioral ▶ Superior treatment option
▶ Plans ▶ Medication may be helpful for
▶ Organization preschool children who have failed
an adequate trial of behavior
▶ Especially for preschool therapy
 Stimulants in general
▶ black box warning regarding their potential for abuse and dependence as well
as for the risk of sudden death and adverse cardiovascular events associated
with their misuse. FDA Drug Safety Communication
▶ In choosing among stimulants, duration of action is primary consideration 
▶ Short-acting forms of medication are often used as the initial treatment in
children <6 years.
▶ Short-acting forms also may be used to determine the optimal daily dose before switching
to a comparable long-acting agent.
▶ In children older than six years, a longer-acting preparation may be used initially,
starting at the lowest dose and titrating up
▶ A combination of a long-acting and late-afternoon short-acting medication may be
necessary to provide adequate coverage in the evening hours for homework completion
or driving
Stimulant Classifications
Short and Long-acting
Methylphenidate class

▶ Concerta 18mg (long acting methylphenidate) up to 72mg

▶ Lower abuse potential – can’t open capsule

▶ Methylphenidate IR (for pre-school or after school dose)

Amphetamines/mixed salts class

▶ Adderall XR (long acting mixed salt) 5mg up to 40mg

▶ Adderall IR (for pre-school or after school dose)

Others

▶ Guanfacine or clonidine – for hyperactivity only

▶ Atomoxetine – if any hx of substance use
Titration
▶ Start at the lowest dose that may produce an effect
▶ increase every 3 to 7 days
▶ until core symptoms improve by 40 to 50 percent compared with baseline
▶ use a Vanderbilt
▶ Teacher feedback is essential. Parents may not be in a position to observe
medication effects on core ADHD symptom and reports from the parents alone
are not sufficient to make a determination of treatment failure.
▶ Effects of stimulant medications on core symptoms usually are apparent 30 to
40 minutes after administration and continue for the expected duration of
action
▶ Inadequate dose may be indicated by a shorter than expected duration of
action
Side Effects
Decreased appetite, Poor Growth, Dizziness, Insomnia/Nightmares, Mood Lability, Tics, Psychosis
Side Effects

Decreased appetite 
• Administer the medication at or
after a meal.
• Encourage the child to eat
nutrient dense foods before those
with "empty calories“.
• Offer food that the child likes for
the noon meal, which is often
affected.
Side Effects

Poor growth
▶ Drug holidays may be
beneficial
▶ Children in whom stimulant
therapy is associated with a
growth trajectory that crosses
two major percentiles (i.e.,
the 5th, 10th, 25th, 50th, 75th,
90th, and 95th)
Side Effects

Dizziness
▶ Monitor blood pressure and
pulse.
▶ Ensure adequate fluid
intake.
Side Effects

Insomnia/nightmares
▶ Omit or reduce the last dose of
the day
▶ If using a long-acting
preparation, change to a short-
acting preparation
▶ Or administer earlier in the
day
Side Effects
Mood lability 
If mood lability occurs at the time of
peak concentration
▶ Try reducing the dose
▶ Or switching to a longer acting
preparation
▶ Irritability, sadness, and increased
activity as the medication wears off
is particularly common when short-
acting medication is used on a
morning and noon twice-a-day
schedule
▶ Try adding an afternoon dose or
switching to long-acting form
Side Effects
Tics
▶ Given the frequency of comorbid tic
disorders and ADHD, and the typical
waxing and waning pattern of tics,
new or worsening tics may be
coincidental.
▶ If tics begin or are worsened in
children taking stimulants, a brief trial
off of medication or at a lower dose
may be warranted.
▶ The trial is most informative if the tics
persist when the medication is
discontinued;
▶ Improvement off of medication or at a
lower dose may be coincidental.
Side Effects

Psychosis 
▶ If children taking stimulant
medications develop psychotic
symptoms (eg, suicidality,
hallucinations, or increased
aggression), STOP.
▶ Stimulant medications can be
discontinued abruptly, without
tapering.
Diversion/Misuse
Predominant motives for illicit use
Improve concentration 28.8%

Increase alertness or stay awake 23.4%

Become high 6.3%

Control appetite 4.2%

Lose weight 3.6%

Enhance exercise 2.6%

Counteract effects of other drugs 2.1%

Experiment or enhance short-term memory 1.2%

Diversion/Misuse

▶ Risk for abuse and dependence associated with the short-term euphoric effects of
stimulants (usually experienced when taken at higher-than-therapeutic doses,
particularly in the immediate- rather than extended-release form).
▶ Those who no longer rely on their own body cues for signs of fatigue and have not
developed effective strategies for replenishing and re-energizing themselves are at
increased risk of excessive use, abuse, and dependence.
▶ Studies estimate upwards of 50% of college age kids with a prescription have diverted
their ADHD medications
▶ Misuse of stimulants can result in behavioral and/or psychiatric difficulties including
irritability, depression, mania, and paranoid thinking/psychosis.
▶ List of banned substances by NCAA
Diversion/Misuse

▶ There is increased vulnerability for abuse and dependence that comes with repeated
misuse of stimulants as more frequent and intense stressors occur as kids progress in
school – find other ways to cope or make changes early on.
▶ High school and college students with ADHD may not be prepared for the social
pressures placed on them to share their medications as well as the potential
consequences for doing so,
▶ Educate them
▶ drug diversion is considered drug trafficking and under federal and state laws is a felony.
▶ Information can be shared about the risks in terms of potential legal problems if they would be
caught diverting medications.
▶ Tell patients to not publicize the fact that they take prescribed medications in the first place to
decrease the likelihood of facing peer pressure or the chance that their pills are at risk for
theft.
Other points

▶ Oppositional Defiant Disorder and ADHD have high overlap

▶ Behavioral Pointers for Parents
Behavior + Attention = More Behavior

▶ Generally, parents leave children alone if they are behaving well, but when children
are misbehaving, they get attention. The attention around the misbehavior actually
increases the misbehavior as a way to get more attention
▶ The best way to improve behavior is to give children a lot of attention when they
are doing something you like and remove your attention when they are doing
something you do not like.
▶ An easy way to increase good behaviors is by describing their wanted behaviors and
praising them when they make a real effort - catch them being good
● "Good job listening the first time!"
● "Good job using your inside voice."
▶ Parents can fill children up with love and attention every day. A very easy way to do
this is to spend quality time with them.
▶ Playing with their children for just 5 minutes will go a long way
▶ When playing with their children, let the kids pick the toy and lead the play. It's
tempting for parents to tell their children what to do or ask a lot of questions, but
it is best not to do that. Try instead to just describe what the children are doing
("You are working so hard to build a tall tower" or "You are stacking those
blocks") and give praise: "Great job sitting so still while we are playing."
▶ Helpful to use toys without rules
▶ You can decrease bad behaviors by ignoring them, but this only works if you are
giving your children lots of attention for their good behaviors.
▶ The simplest way to do this is through planned ignoring. Ignoring means not
talking to, looking at, or touching your children when they are behaving badly.
▶ The key to ignoring is making sure to give your children positive attention as
soon as the bad behavior stops, like saying:
● "You are quiet now; it looks like you are ready to play."
● It is important to not ignore unsafe behaviors that need immediate attention from
you.
▶ www.Healthychildren.org