Attention Deficit Without Hyperactivity: ADHD, Predominantly Inattentive Type

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1 Page 1 This webcast has been supported by PharmCon Attention deficit without hyperactivity: Predominantly Inattentive Type ADHD Dr. Ellen Wilson, RPh, PhD PharmCon is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education Legal Disclaimer: The material presented here does not necessarily reflect the views of Pharmaceutical Education Consultants (PharmCon) or the companies that support educational programming. A qualified healthcare professional should always be consulted before using any therapeutic product discussed. Participants should verify all information and data before treating patients or employing any therapies described in this educational activity. Accreditation: Pharmacists: L01-P Technicians: L01-T Nurses: N-669 Attention deficit without hyperactivity: Predominantly Inattentive Type ADHD CE Credits: 1.0 contact hour Target Audience: Pharmacists, Technicians & Nurses Program Overview: Attention-Deficit/Hyperactivity Disorder is a syndrome of behaviors characterized by inattention, hyperactivity, and impulsivity. ADHD affects approximately 10% of the childhood population and it is estimated that somewhere between 10 and 60 % of childhood ADHD cases will persist into adulthood. Even though the exact cause or causes of ADHD are unknown, it is known that ADHD is a neural-chemical problem that effects the management systems, or executive functions of the brain. While the stereotypical child with ADHD exhibits many hyperactive and impulsive behaviors, there are actually three subtypes of ADHD: predominantly inattentive type, hyperactivity-impulsive type, and combination type. Boys are at least two times as likely to be diagnosed with ADHD than girls, but girls are more likely than boys to have inattentive type ADHD. These school-aged girls are often not diagnosed because they sit quietly in their seats and do not pose a discipline problem in the classroom. This program will define ADHD and its subtypes, discuss possible causes, review the structures of the brain thought to be affected in ADHD, define executive function, and discuss current treatment options. And emphasis will be placed on presentation, diagnosis, and treatment of girls with inattentive-type ADHD. Objectives: Define the term attention-deficit/hyperactivity disorder, its subtypes, and the overall incidence of ADHD in both child and adult population Review the etiology of ADHD as well as dispel some of the myths associated with this disorder Identify current treatments for children with ADHD with an emphasis on predominantly inattentive type ADHD This webcast has been supported by PharmCon Attention deficit without hyperactivity: Predominantly Inattentive Type ADHD Speaker: Ellen Wilson is a freelance educator based in Greenville, SC. She received a B.S. in Pharmacy and a PhD in Pharmaceutical Sciences from the University of South Carolina. Her pharmacy practice experiences include retail, hospital, and consulting pharmacy. She also has nearly ten years of collegiate teaching experience at both four-year and two-year institutions. Currently, she teaches online chemistry courses and writes pharmacy continuing education. Ellen lives in Greenville with her husband, two daughters, one cocker spaniel, and a once-stray cat. She is an active volunteer at both church and school, enjoys gardening and backyard birding, and is trying to master the art of French cooking. Speaker Disclosure: Dr. Wilson has no actual or potential conflicts of interest in relation to this program This webcast has been supported by PharmCon PharmCon is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education Legal Disclaimer: The material presented here does not necessarily reflect the views of Pharmaceutical Education Consultants (PharmCon) or the companies that support educational programming. A qualified healthcare professional should always be consulted before using any therapeutic product discussed. Participants should verify all information and data before treating patients or employing any therapies described in this educational activity. Define ADHD dispel myths Review Etiology including the brain, executive function Objectives Discuss treatments including the consequences of no treatment

2 Page 2 Inattentive 43% DSM-IV Criteria for ADHD-I (at least 6 of 9, at least 6 months) What is ADHD? What is attentiondeficit/ hyperactivity disorder? Combined Hyperactive- Impulsive 32% 25% Lack of attention, careless errors Difficulty sustaining attention Seems not to listen when spoken to Difficulty with sustained mental effort Difficulty organizing Fails to finish work/duties Often loses necessary items Easily distracted Often forgetful DSM-IV Criteria for ADHD-HI (at least 6 of 9, at least 6 months) Inattentive Fidgets and squirms Leaves seat when sitting is expected Runs or climbs excessively Difficulty playing quietly Driven by a motor Talks excessively Blurts out answers Difficulty waiting turns Interrupts or intrudes on others What is ADHD? What is attentiondeficit/ hyperactivity disorder? Combined ADHD-C Hyperactive- Impulsive

3 Page 3 Incidence of ADHD Generally appears in childhood, affecting 6-9% of the childhood population Co-morbid Conditions Oppositional Defiance Disorder (41%), Minor Depression/Dysthymia (22%) and Generalized Anxiety Disorder (15%) Myth #1 Myth Truth ADHD must be diagnosed in childhood. Many children and teens suffer ADHD without a correct diagnosis. Incidence of ADHD Approximately 4% of adults are diagnosed with some type of ADHD

4 Page 4 Inattentive Type Why are children with this type of ADHD often overlooked? ADHD CAN PRESENT VERY DIFFERENTLY IN GIRLS THAN IN BOYS What causes ADHD? Neurotransmitters: Biosynthesis B. Much Evidence Neurochemical Genetic A. D. C. Some Evidence Environmental Factors

5 Page 5 Norepinephrine Planning & vigilance Working memory & arousal Behavior inhibition, alertness & attention Dopamine Motivation & movement Problem solving & decision making Memory, pleasure & mood Behavior inhibition, alertness & attention Neurotransmitters: Dopamine Degradation Genetic Factors Environmental Factors: Maternal Smoking

6 Page 6 Environmental Factors: Low Birth Weight (<5 lbs, 8oz) Environmental Factors: Maternal Alcohol Use Environmental Factors: Lead Exposure Environmental Factors: Phthalate Exposure Present in LBW infants Levels in children Prenatal exposure Lead level >2 mg/dl 5mg/dL 10mc/dL ADHD Risk 4.1X 4.1X CDC action level ADHD?

7 Page 7 Environmental Factors: Food Additives Myth #2 Myth Truth ADHD is caused by poor parenting, excessive junk food, and too much TV. There is far more evidence to suggest a genetic basis for ADHD. Myth #3 The Brain and ADHD Myth Truth ADHD is caused by a lack of willpower. People with ADHD should just try harder. ADHD is a neuralchemical problem that effects the brain & its executive functions.

8 Page 8 The Brain and ADHD Brain Maturation in ADHD Functions of the prefrontal cortex Working memory Focus of attention Change of focus Suppression of inappropriate thoughts/actions The management system of the brain The management system of the brain Activation Activation Action Focus Action Focus Executive Function Executive Function Memory Effort Memory Effort Emotion Emotion

9 Page 9 The management system of the brain The management system of the brain Activation Activation Action Focus Action Focus Executive Function Executive Function Memory Effort Memory Effort Emotion Emotion The management system of the brain The management system of the brain Activation Activation Action Focus Action Focus Executive Function Executive Function Memory Effort Memory Effort Emotion Emotion

10 Page 10 The management system of the brain Myth #4 Action Activation Focus Myth Truth Memory Executive Function Effort You either have ADHD or you don t. ADHD symptoms occur on a continuum of severity. Emotion ADDITUDE Living Well with Attention Deficit Treatment of ADHD Stimulant Nonstimulant Other Not like pregnancy A continuum of symptoms Methylphenidate Various forms of amphetamine Atomoxetine Clonidine Guanfacine Bupropion TCA MAOIs

11 Page 11 Stimulants Stimulants Short-Acting Mechanism of Action Inhibit DA Transporter methylphenidate Amphetamine salts, dexamphetamine Increase DA release Amphetamine salts, dexamphetamine Generic/Brand Name Methylphenidate (Ritalin, Methylin ) Dosages (mg) Duration (h) 5,10, Dexmethylphenidate (Focalin ) 2.5,5, Mixed amphetamine salts (Adderall ) Dextroamphetamine (Dexedrine, Dextrostat ) 5,7.5,10, ,20, , Stimulants Long-Acting MPH Stimulants Long-Acting AMPH Brand Name of MPH Dosages (mg) Duration (h) Ritalin SR Metadate ER, Methylin ER 10, Focalin XR 5,10, Metadate CD 10,20,30,40 50, Ritalin LA 10,20,30, Concerta 18,27,36, Daytrana (transdermal patch) 10,15,20, Generic/Brand Name Dosages (mg) Duration (h) Amphetamine (Dexedrine Spansules ) 5,10, Mixed amphetamine salts (Adderall XR) Lisdexamfetamine (Vyvanse ) 5,10,15,20, 25,30 20,30,40,50 60,

12 Page 12 Common appetite & weight, slowed growth Abdominal pain Tachycardia Insomnia irritability nervousness Stimulants Side Effects Possible Cardiac events BP & HR Psychosis, bipolar events, aggression Seizures, visual Nonstimulant Medication Mechanism of Action Atomoxetine (Strattera ) Blocks NET in the prefrontal cortex Increases NE & DA levels Nonstimulant Nonstimulants Side Effects Generic/Brand Name Atomoxetine (Strattera ) Dosages (mg) 10, 18, 25, 40, 60, 80, 100 Duration (h) 24 Common BP & HR appetite & weight Nausea, dizziness Insomnia, fatigue irritability Possible Suicidal ideation Hepatotoxicity

13 Page 13 Treatment of ADHD Alternative Treatments for ADHD Other Clonidine (Kapvay ) Guanfacine (Intuniv ) Bupropion TCA MAOIs Diet Supplements Interactive Metronome Feingold/sugar Some support Fatty acids & glyconutrition Some support 1 study w/boys Some support Alternative Treatments for ADHD Myth #5 Antiemetics meclizine Not valid or consistent Myth Truth Chiropractic Vision Therapy Spinal & cranial adjustment No support Eye & perceptual training No support Pharmaceutical treatment will lead to future drug abuse. Pharmaceutical treatment decreases the risk of future destructive behaviors.

14 Page 14 Thank You Adams, C. ( May). Girls & ADHD: Are you missing the signs. Retrieved May from Scholastic Instructor: Bauchner, H. (2003, Dec 23). Response to medication differs for ADHD subtypes. Journal Watch Psychiatry, 1. Brown, T. E. (2002). DSM-IV: ADHD and executive function impairments. Advanced Studies in Medicine, 2 (25), Brown, T. E. (2008 Feb). Executive Functions: Describing Six Aspects of a Complex Syndrome. Attention, Brown, T. E. (2005). Inside the ADD Mind. In T. E. Brown, Attention Deficit Disorder: The Unfocused Mind in Children and Adults (pp. 1-20). New Haven, CT: Yale University Press. Castle, L., Aubert, R. E., Verbrugge, R. R., Khalid, M., & Epstein, R. S. (2007). Trends in Medication Treatment for ADHD. Journal of Attention Disorders, 10 (4), Children and Adults with Attention-Deficit/Hyperactivity Disorder. (2008, Jan 30). Complementary and Alternative Treatments for AD/HD. Retrieved Jun 18, 2011, from National Resource Center on AD/HD: Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD). ( Feb). The Disorder Named ADHD (WWK1). Retrieved May from National Resource Center on AD/HD: Elan Drug Technologies. (2010, Dec 31). SODAS Multiparticulate Delivery System. Retrieved Jun 12, 2011, from Elan Drug Technologies: Gaby, A. R. (2008). Food additives and hyperactivity: Feingold was right. Port Townsend, WA: Townsend Letter. Geller, B. ( Jan). ADHD: Advances in Knowledge in Retrieved May from Journal Watch Psychiatry: AC- Documents&type=retrieve&tabID=T002&prodId=AONE&docId=A &source=gale&srcprod=AONE&userGro Kim, B.-N., Kim, J.-W., Kang, H., Cho, S.-C., Shin, M.-S., Yoo, H.-J., et al. (2010). Regional differences in cerebral perfusion associated with the alpha-2aadrenergic receptor genotypes in attention deficit hyperactivity disorder. Journal of Psychiatry and Neuroscience, 35 (5), Kim, J., Biederman, J., McGrath, C., Doyle, A., Mick, E., Fagerness, J., et al. (2008). Further evidence of association between two NET singlenucleotide polymorphisms with ADHD. Molecular Psychiatry, 13, Langley, K. et al. (2007). Effects of low birth weight, maternal smoking in pregnancy and social class on the phenotypic manifestation of Attention Deficit Hyperactivity Disorder and associated antisocial behaviour: investigation in a clinical sample. BMC Psychiatry, 7 (26),

15 Page 15 May, D. E., & Kratochvil, C. J. (2010). Attention-Deficit Hyperactivity Disorder: Recent Advances in Paediatric Pharmacotherapy. Drugs, 70 (1), McNeil-PPC, Inc. (2002). Stimulant Medications and ADHD--Fact Sheet. Titusville, NJ: McNeil Consumer & Specialty Pharmaceuticals. National Institute of Mental Health. ( May). Brain Basics. Retrieved May from National Institute of Mental Health: National Institute of Mental Health. ( Nov). Brain matures a few years late in ADHD, but follows normal pattern. Retrieved May from National Institute of Mental Health: Office of Information Services. ( Feb). FastStats Homepage. Retrieved May from Centers for Disease Control and Prevention: Staller, J. A., & Faraone, S. V. (2007). Targeting the dopamine system in the treatment of attention-deficit/hyperactivity disorder. Expert Review of Neurotherapeutics, 7 (4), Staller, J., & Faraone, S. V. (2006). Attention-Deficit Hyperactivity Disorder in Girls. CNS Drugs, 20 (2), Stein, M. T. (2007, Aug 15). Boys and girls with ADHD have different responses to methylphenidate. Journal Watch Pediatrics and Adolescent Medicine, 1. U.S.Public Health Service. ( May). Attention-Deficit/Hyperactivity Disorder. Retrieved May from Mental Health: A Report of the Surgeon General: Maternal Smoking: Ball, S. W. (2010). Revisiting the association between maternal smoking during pregnancy and ADHD. Journal of Psychiatric Research, 44 (15), Braun, J. M. (2006). Exposures to environmental toxicant and attention deficit hyperactivity disorder in U.S. children. Environmental Health Perspectives, 114 (12), Potera, C. (2007). Secondhand behavioral problems. Environmental Health Perspectives, 115 (10), A492. Tillett, T. (2006). Adding up to ADHD: effects of early exposures. Environmental Health Perspectives, 114 (12), A715. Maternal Alcohol Use: Fryer, S. et al. (2007). Evaluation of psychopathological conditions in children with heavy prenatal alcohol exposure. Pediatrics, 119 (3), Linnet, et al. (2003). Maternal lifestyle factors in pregnancy risk of attention deficit hyperactivity disorder and associated behaviors: Review of the current evidence. American Journal of Psychiatry, 160, Mick, E. et al. (2002). Case-control study of attention-deficit hyperactivity disorder and maternal smoking, alcohol use, and drug use during pregnancy. Journal of the American Academy of Child and Adolescent Psychiatry, 41 (4),

16 Page 16 Lead Exposure: Braun, J. M. (2006). Exposures to environmental toxicant and attention deficit hyperactivity disorder in U.S. children. Environmental Health Perspectives, 114 (12), Tillett, T. (2006). Adding up to ADHD: effects of early exposures. Environmental Health Perspectives, 114 (12), A715. Food Additives: Feingold, B. F. (1975). Hyperkinesis and learning disabilities linked to artificial food flavors and colors. American Journal of Nursing, 75 (5), Pelsser, L. M. (2009). A randomized controlled trial into the effects of food on ADHD. European Child and Adolescent Psychiatry, 18 (1), Phthalates: Bung-Nyun Kim, et al. (2009). Phthalates exposure and attentiondeficit/hyperactivity disorder in school-age children. Biological Psychiatry, 66 (10), The Centers for Disease Control and Prevention. ( Feb). Fact Sheet: Phthalates. Retrieved Jun from National Report on Human Exposure to Environmental Chemicals: Engel, S. M. (2010). Prenatal phthalate exposure is associated with childhood behavior and executive functioning. Environmental Health Perspectives, 118 (4), Zhang, Y. et al. (2009). Phthalate levels and low birth weight: A nested casecontrol study of Chinese newborns. The Journal of Pediatrics, 155 (4), Notes Notes