ADHD: Attention Deficit Hyperactivity Disorder

this program is a presentation of uctv for educational and non-commercial use only welcome to the University of California Davis health system since 1973 continuing medical education CME has been an integral part of the educational mission of the UC Davis School of Medicine and Medical Center the Center for health and Technology CHT increases access to health education and promotes interaction between patients physicians and other health care professionals through the use of telecommunications and computer technology hello I'm dr. Jeffrey Applebaum and I'm here today to spend an hour with you on the topic of ADHD and some of its comorbidities both in children adolescents and adults I'm here with my nurse today Stephanie and she has been with me for the past ten years we have been through a lot together in those ten years and we've had some very interesting stories to tell I sometimes spend more time I think in the office than at home and with that I'd like to share some of my information that I've learned and gleaned over the last actually 14 years in the office as well as my 30 years of practice and dealing with patients with ADHD at this point what I'd like to do is first tell you who I am I have been involved in primary care medicine and primary care psychiatry over most of my career and that would be approximately 30 years during this time even when I was in private practice before the university I was seeing patients regularly and I had about 6 months of training in psychiatry but most of the time that I've learned psychiatry has been spent in the office and then additional training to let you know further I have been involved with the neuroscience education institute UC San Diego and Steven Stahl who has been a great teacher of psychiatry of psychopharmacology in addition I have been a speaker around the country for Forest Laboratories AstraZeneca and prior speakers for Lilly Cephalon and GlaxoSmithKline at this point what I'd like to do is have you look at something that I enjoy having people take a look at and that's an elephant so tell me out there in the audience what did you just see let me go back and now you've spent just a little bit more time and as you spend a little more time you see that this elephant doesn't look quite right and why well when you spend more time looking at something when you see a little bit more depth and understand the next level down and that's what I'd like to talk about with regard to ADHD is that let's look for a few minutes and see what's below the surface in ADHD when we look at mood disorders if you have a patient that comes in with any type of a mood disorder at least one of them has ADHD if you look at a patient that is first diagnosed with ADHD four also have a mood disorder and when you have a patient diagnosed with ADHD five also have an anxiety disorder in addition to the ADHD what I developed starting about eight to nine years ago was a primary care algorithm in order to help primary care physicians and other primary care providers learn how to deal with psychiatry in general within a 15-minute office interview very often we get confused and when we see a patient with depressive symptoms we immediately say this patient has depression or a patient with anxiety we say you have an anxiety disorder when in fact these are the symptoms of something often more complex so in order to go to the core features of each of the illnesses that I'm talking about today and what I've talked about in the past I'd like to give you an algorithm that you can use starting this afternoon in your office and start to understand how to differentiate the different medical problems that you would see in a primary care practice the algorithm I'm going to leave up here now for a few minutes while I talk about it because this was the algorithm that I brought up during my last session that we videoed about a year ago and in this algorithm there are four decision points that you need to take into account and this could be done in a 15-minute interview the first most patients come in with depression and anxiety combined when you see them in a primary care setting and because of that what we first question we need to know is is it an anxiety disorder or is it a depressive disorder and when you look at the anxiety disorders these patients are people that worry about the future patients that have a depressive disorder dwell in the past it's very simple if patients are talking about anxiety and depression combined you simply ask them based on your lifestyle what do you do do you dwell in the past typical of depression do you worry about the future that's an anxiety disorder if they worry about the future and it's an anxiety disorder you look at one of five anxiety door disorders typically they're not in any particular order but generalized anxiety disorder is a condition that typically lasts for at least six months or longer and there's a great deal of worry and anxiety about multiple topics and subjects throughout the entire person's life and about all subjects and topics in their life panic disorder is something that comes without a particular precipitating cause often awaken somebody from sleep and results in that panic feeling that results often in an emergency room visit in the middle of the night social anxiety disorder where you have fears about speaking in front of others or other phobic conditions is another form of an anxiety disorder the other two are sometimes harder to tease out the post-traumatic stress disorder due to some life-threatening event or emotional stressful event that is often hidden behind the scenes because patients are embarrassed about discussing that but often leads to extreme consider considerable anxiety and often considerable depression one out of every four patients with chronic post-traumatic stress disorder actually commits suicide obsessive-compulsive disorder is another that is often hidden because patients remain very embarrassed about talking about obsessive compulsive compulsive disorder issues their compulsive behaviors or their obsessive behaviors and the third if you find a patient that has depression the next step is to look at whether it is a unipolar or bipolar depression if it is bipolar these patients usually have considerable mood lability they get depressed very quickly mood can go from normal or irritability down to depression not over weeks to months like unipolar but in moments minutes a day they go into severe depression that may last anywhere from a few days to a few weeks or even in two months the rule of threes is three failed marriages three failed trial ivenna of antidepressants and three failed marriages so the marriages jobs and the antidepressants are issues that often suggest dysfunction in these patients they have a loaded family history that family history includes others with bipolar possibly ADHD schizophrenia drug abuse alcoholism suicide people in jail so when you find somebody with bipolar you're seeing much more than in the unipolar and the early age of onset bipolar tends to occur at the age of 13 14 15 where unipolar often occurs initially in the late 20s finally we're coming up to the topic for today how do you differentiate bipolar disorder from ADHD there is often a lot of impulsivity difficulty with focus concentration distractibility often both issues on mood problems issues on conduct disorder it could be stealing lying fire setting there could be problems with substance abuse and they often look very much like one another however very quickly you could differentiate in most cases because ADHD at the core feature is a cognitive disorder it starts with problems with focused concentration that you often see in school and later deals with mood often months two years later the onset of ADHD is often seen between five and seven on the other hand bipolar disorder is a condition that is often seen initially at 13 14 15 sudden onset of mood changes mood lability and irritability not necessarily the classic mania or hypomania and depression you see in adults but some change in mood that Lynne then leads to cognitive dysfunction later again there's a difference in age there's a difference in cognition being the core feature of ADHD is a problem and a mood disorder being the core feature of bipolar so there you have the the issues of the algorithm and when I see a patient that has a complaint of depression with anxiety the first thing I will say to them is do you dwell in the past or do you worry about the future if they worry about the future I figure out which of the anxiety disorders they have if they dwell in the past and I figure this is a depressive disorder I differentiate unipolar by bipolar in about another seven or eight minutes and then if I think they may have bipolar I try to differentiate is it ADHD or bipolar or both and that is what takes up this 15 maybe 20 minutes for the algorithm that tends to work quite well now Stephanie you and I see this occur on a regular basis we have patients come in with a whole variety of complaints what's what's your thought I I'm looking from my perspective in the room but you see the patient even before they get into the room and while they're having their vital signs taken sometimes I'm I'm surprised what the diagnosis they come out of the room with they're going in with complaints of maybe depression anxiety substance abuse maybe alcohol talking about alcoholism and then they come out like I said with the the diagnosis of 80 deal so I you know I wonder sometimes where you know where does that come from you know it doesn't seem like it fits to me so what you know why don't you maybe why don't you tell tell the audience about the story of the breadcrumbs well that's a fun story and it's it's followed the breadcrumbs that's one of my mantras when I take histories in psychiatry and just before I do that what I'd like to do is show the next slide in which we were talking about what stephanie was just saying if you look at cold morbidities in the psychiatric disorders with a DD you're gonna find other conditions it's very rare for adults in particular to have what we call ADHD complex or simplex what we're talking about in children you often see the cognitive dysfunction start around 5 to 7 this is the problem with focus and concentration as they're going into school they may have had some problems with irritability and other issues but it's really when cognition is key in the early ages of school that you start understanding what ADHD is all about they cannot focus and concentrate well because of that if you think of that as the center of an onion as the onion grows and gets a little bit larger if they're not doing well in school they become anxious and tense and depressed why because they're not doing well they don't keep up they're falling further behind they get very frustrated so that onion has grown to a new level and a little bit larger from there the next step beside the frustration and that you start getting into oppositional defiant disorder which is often associated that's where the kids argue with everything the parent says and everything often that the teacher says it does so as a result you've got a very argumentative child we've had a number of those the worst was one that was throwing water balloons in the office in one of my patient visits that really gets a little difficult to deal with but from there you get into problems with conduct disorders and the conduct disorders are often fire setting stealing other issues lying so that the parents lose faith and trust in their children and this onion continues to grow and often it grows because these children are not treated typically with medication you cannot take a child to counseling like you do an adult medication is the key factor and counseling along with the medication often in the primary care office is often very helpful if you choose let's say the patient chooses not to be treated or the parents not to have the child treated then you go to the next level which is often substance abuse and the substance abuse choice is marijuana yeah by far you see other drugs but when people talk about stimulant meds those often help the children focus and concentrate when these children get frustrated they want something to help them relax and they typically turn to marijuana perhaps later alcohol and from there then you get into difficulties with work and inability to maintain a job the the saying is I tried and I tried and I failed in relationships the impulsive behavior the difficulty dealing with with sexual partners with friends and family become much more difficult and these patients often become more and more frustrated over time so then they start later turning to alcohol and sometimes other substance abuse to try to deal with their frustrations so this is what I'm dealing with when I see patients with a DD I make the diagnosis they're having problems with cognition from childhood they've added on these layers of the onion that I peel away and come back to the core feature of the condition so let's take an example here and this is one that I enjoy talking to you about at this point we can put the slides away I think at this point and what I'll do is tell you about a case that demonstrates how this takes place and I call this follow the breadcrumbs I had a patient come in to see me a 30 year old woman I was on call covering one of the other doctors and at that point a woman came in with a typical muscle ache soreness in the upper back jaw was aching a little bit of headache typical musculoskeletal type complaints and very often it would be easy for someone to say after a little of exam here are some ibuprofen and muscle relaxant off you go follow up with your regular physician and you'll be all set and move on to the next patient takes five minutes however in talking to her I saw the she was anxious about many different things she would wake up with headaches she was tender over the temporomandibular joints this often goes with bruxism grinding the teeth at night from stress and indeed the more I talked to her the more I saw that she worried about everything there wasn't anything in her life that she didn't worry about she had two boys she had a husband she had an outside job part-time nothing went smoothly for her so beside little ibuprofen I put her on an SSRI very low dose initially and then gradually built that up and added a dose of klonopin at bedtime to help her sleep and relax the muscles she came back in a month and she said she felt a world of difference better in fact she didn't even need the motrin after the first couple of weeks and she gradually brought the SSRI up she was taking the klonopin and she was doing great she decided she would follow up with me because she wanted to give me the good news how well she was doing and she even relayed to me the fact that her son their seven-year-old who was in second grade usually was a bother to her she had problems controlling him but overall he was a good boy however he would take his coat and fling it around at kindergarten and then at first grade said great and he was bothering all the children so he would be told to stay in at recess time and he would stay in and then a few weeks later he did the same thing all over again and she said you know in the past before the medicines it would have bothered me to no end now I'm calm and relaxed and I can let it slide by no problem whatsoever here's another bread crumb the patient was throwing out if you don't follow the bread crumbs you lose the trail what was the next question to ask that would be sounds like your son has difficulty with impulsivity not uncommon in boys at the age of seven but at the same time he didn't learn by his behavior and and the what do you call a punishment or what what happened afterwards he did the same thing all over again so I asked her by any chance does your son have any problems learning with focus and concentration and she said how did you know they're coming in tomorrow at school to evaluate him for a DD this is attention deficit disorder or attention attention deficit hyperactivity disorder and he fit the bill for hyperactivity and problems with attention so I talked to her for a moment and it would have been easy to say let's have you take your son in to the pediatrician or bring him in to see me but before I let her go I asked her by any chance do you have ADHD you don't seem to me the type that has it based on what I've talked about and seen with you and she said no well I know it's heritable about 50% heritable so if she doesn't have it somebody else has it and it's probably her husband so I asked following the breadcrumbs what about your husband does he have any problems with focus concentration memory impulsivity forgetting things at work home she's how did you know and she said at work he gets there late every day he struggles at work by the time he comes home he's so frustrated because he's been losing track of things he loses things he can't get the job done he tries and tries and often fails that what he tries to do he's an accountant so it's very important that he'd be very compulsive and yet he has a great deal of difficulty so by the end of that visit I knew that she has general anxiety disorder she worries all the time her son is most likely as ADHD and her husband the father of this boy also has ADHD this was on a about on a Tuesday I said why did you all come in on Friday and we'll have a group session at least to put it all together and then you can decide how you want to deal with it turns out the boy ended up going for treatment the father had been doing reasonably well and he decided that he did not desire to be on medication he had compensated reasonably well but at least he knew where he stood and now the wife knew where she stood and she was not quite as frustrated all of that started with a single visit for neck and upper back pain a little bit of jaw pain that led all the way down to these psychiatric diagnoses in about four to six weeks and all started the appropriate treatment this is what I mean by follow the breadcrumbs because you can stop at any point but sometimes just one or two questions further gives you a better feeling of what that elephant really looks like so let's look at the treatment of ADHD at this point what we're looking at currently is the fact that there are many different forms of treatment for ADHD it really depends on whether you're dealing with a child and adolescent or an adult very often the adults already are misdiagnosed and they may have a problem with anxiety depression substance abuse especially at this point alcohol sometimes marijuana and so when you're looking at adults what you want to look at is the fact that you want to treat for these other conditions but you always want to keep in mind that ADHD could be behind the scenes so if you do find that often I'll put patients on a small amount of treatment including a stimulant medication followed or along with an SSRI and perhaps a small amount of benzodiazepine for anxiety and insomnia at night very often when you treat like this patients will stop substance abuse their anxiety and depression once they are able to focus and concentrate that's much better and you can see the improvement with stimulant medications very quickly in adults for children adolescents I often will then again start early on with stimulant medication if I find that the children already have depression and anxiety I will add a small amount of an SSRI and there are there are certain ones that are better I think to use than others and I tend to stay away from paroxetine and venlafaxine and children adolescents because they have a very short half-life and because of that if they stop the medication or it stopped they can have significant withdrawal or discontinuation syndrome so if we know this information as a basis we have lots of treatment choices when we have ADHD let's start with the children and adolescents we have an ADHD pharmacy here and we're going to start with the lowest level and you see there's two first-line stimulant level of medication I tend to choose the amphetamine category more than the methylphenidate category the amphetamine category started a small dose and titrated upward to me is very effective and I find it works quite well it has extra beneficial effect metabolically in that it causes the release of dopamine as well as the prevention of the reuptake of dopamine so it has a stronger two mechanism effect as compared to methylphenidate which blocks the reuptake but does not cause a release of the vesicles of dopamine when we're looking at the medication I prefer always the long-acting if I can go with the long-acting medication the only reason I can't would be one if it's too expensive and lack of insurance or the long-acting is causing too much suppression of appetite or problem with sleep one of the medications that I've that I like very much is the medication which is known as vyvanse as the brand name and the reason I like that it is a form of the adderall xr it's a form of the amphetamine along in the extended-release along with a lysine molecule that's attached to that amphetamine molecule in the body and the gut that lysine molecule is cleaved off in this stomach and by about 10 percent of that and the rest is metabolized in the bloodstream to form the pure the dextroamphetamine which has a long-acting effect from morning until late afternoon or early evening the beneficial effect here is that you cannot abuse this drug what do you do is you take it orally it gets into your system quite quickly and it stays in till the evening if it's too strong you open up the capsule pour it out into juice or perhaps on some yogurt and you could take part of that day in part the next day what you're gonna find is with the amphetamine category and the methylphenidate category what you want to do is look for the medications based on how long they last and the peak effectiveness for example concerta starts slowly in the morning may take an hour - and then last into the evening as one of the methylphenidate drugs medidate CD starts quickly in the morning and ends at about 3:00 or 4:00 in the afternoon so a child in elementary school could have that medication and it ends by three or four Charles out of school doing well no problem with eating or sleep at night but if you have a child that needs to study at night you may want a drug that goes into the evening hours such as the concerta or some of the other longer acting medication but one of the important things you want to get a high peak early you want to get sustained drug effect until the evening hours especially in adolescents and adults so that they don't get the pulse Atal effect of stimulation and then no stimulation that is where sometimes people will get into trouble they try to dose themselves frequently during the day and it makes it more difficult to know exactly when you need the dose sometimes you take it a little too late there's more chance of abuse if the brain is being stimulated strongly by an amphetamine or methylphenidate but again more on the amphetamine side and so it's best to have a sustained effect rather than a pulsatile effect in children and adolescents we can go on to other second-line stimulants as you see here there's a lot of abbreviations and I'll at the end spend this a little bit of time showing you the slides with the names because it's a lot easier if you have some brand names in this day and age when you have so many different medications the second line non stimulants are often helpful and this is a category of other medicine atomoxetine strattera has been around for now a few years and it has a blockade of norepinephrine reuptake so you get more norepinephrine or epinephrine in the frontal lobes that increase in norepinephrine helps with focus and concentration it does not have as much antidepressant effect as it does for the ADHD what's interesting is dopamine is also taken up by norepinephrine transporters so if you block norepinephrine transport in the frontal lobes you not only increase norepinephrine but you secondarily downstream increased dopamine in the frontal lobes and it's primarily a dopamine effect that we're trying to get especially in the frontal lobes of the brain also in other other areas like the striatum which has to do with some of the motor function and impulsivity and then you don't want high intensity in the limbic area especially in the area of the limbic system and the nucleus accumbens that is the area we call the pleasure center pleasure seeking where when people abuse drugs especially the stimulants they're trying to get a strong effect in that nucleus accumbens which gives them that's high and that desire to come back and have more and that's what we try to avoid often parents will ask me am I going to turn my child into a drug addict by giving them medication and my answer to them is definitely not when patients get the right medication that they need for the brain they don't go out and seek other over-the-counter or drugs of abuse those that do abuse are those that have not been treated typically so when you give a medication that increases dopamine in the frontal lobes they will do better that's why the stimulant meds I like to do that because most patients need to have that problem corrected quickly not over weeks to months such as the atom oxygen there are two others on this second line non-stimulant clonidine and guanfacine ER the guanfacine extended release is also known as intuitive which also increases norepinephrine in the Loeb and is especially helpful in patients that also have oppositional defiant disorder so this combination of medication you can pick from the first line you can add a second line there are others you can even add into the third line and I tend not to use a lot of the tricyclics because of their potential toxicity but you have the norepinephrine dopamine reuptake inhibitor such as wellbutrin in the SR XL formulation and you can go about 150 even up to 300 milligram which is the full adult dose and the SNR eyes are also helpful such as cymbalta and effexor so you have a whole variety of medications sometimes parents will ask me why are you giving a stimulant to a child that's already looking like you sped up and who's thinking and jumping from one topic to the other well the problem is not so much that you're stimulating when I Drive a car I as a learner I better learn where the brake is before I learn where the gas pedal is and if I stimulate the gas pedal I'm gonna go faster if I stimulate the brake I'm gonna go slower and these stimulant drugs stimulate the brake not the gas pedal and the way they stimulate the brake is to increase the tonic stimulation of the frontal lobes which have to do with maintenance of long-term focus and concentrations it's what we call our sustained concentration our sustained focus if I tell you in the audience I want you to pay attention right now you've got an important test coming up in two minutes you're all going to have sudden selective attention and you use a different part of the brain we call it the anterior cingulate deep in the brain we use that to gain attention selective attention but if I drone on for 10-15 minutes or half hour you're gonna lose attention very quickly that is the sustained attention of what we call the dorsal lateral prefrontal cortex and if you wonder where that is just look and put a finger above your right eye on your on your forehead and right above there behind that part of the bone is your dorsal lateral prefrontal cortex where you maintain sustained attention that's also where you have problem-solving that's also where you have your short-term memory where you have memory that can hold seven different objects so that you can listen and talk and maintain a conversation so that you can understand and study that area is significantly affected in patients with ADHD because of lack of dopamine receptors that help that area at work so there's certain genetic basis behind this we know 50% in heritability in this condition higher than many of the others in it about as high as schizophrenia we also see that we need to maintain tonic stimulation in our frontal cortex so that we can concentrate and focus maintain control if you were to say to me what does the frontal lobe do one of the strongest things that does it makes us do the right thing why do I say that if you need to go to school and study and not go out and play and have fun it's your frontal lobe that tells you stay in and study because someday I may want to become a psychiatrist or a an attorney or an accountant or a truck driver whatever you want to be you need that frontal lobe working so that you can maintain sustained attention problem solving and that's why it's so critical that children start at an early age because every year that that onion grows you add more problems and if at 8 9 10 11 12 13 you end up not having good focus concentration you're not going to be a good student and you're going to look for the a different way out very often to substance abuse marijuana alcohol and getting in touch with kids and friends that are not going to go the direction that your parents want it to so we have adjunctive therapy too and when things really get to be a problem we sometimes will go to our atypical agents we have medications in the range of Seroquel abilify zyprexa we have a whole variety but it also include counseling from the primary care there are many easy ways to counsel when you see children adolescents one of the biggest things that happens is that those children often have the thought I've tried and tried and I failed I'd like to do it but I can't I'm making an effort and I failed again so when they find that there's a way of controlling that issue of focus and concentration they are much improved in fact often with a lit of medication and understanding what they have they turn around in sometimes days and weeks I've seen children that have not been able to do well in math at all getting all the right answers and the teachers say Johnny you can put your hand down let's let some of the other kids answer some of the questions they have done so well so quickly and they come back within a month bright cheerful sometimes they don't need the additional SSRI medication when they are on the proper SSRI dose you can keep that going but the stimulant med will often be the answer as you titrate that up when we look at adults it's very similar I would say that my first line for most adults especially if they're not an abuser of drugs would be to go with the stimulant medication also I try to make sure I have a good history to make certain that these patients are getting the right diagnosis first and that they don't have contraindications cardiac problems diabetes history of stroke most the patients that I see are in their 20s and 30s that have not been diagnosed and when they get on medications they they blossom they will start reading they'll do better and work and I look at the medications very often to work as quickly as we can I do not want a medicine that's going to take two or three months because they have struggled some of them are one step out of jail one step out of a marriage or a job so I see most of these people in some form of crisis and the stimulant meds will do much better than the non-stimulant let's say strattera which may take one or two or three months to get to where i want it to be it's a good adjunct but I would not necessarily even know it's on here put it as my first line Intuniv has been indicated primarily for children adolescents but some adults will receive that and can do well otherwise you could use clonidine as another medication modafinil or provigil has been used and it is a non stimulant it is a pro histamine drug that increases histamine in the cortex which is helpful if you think of benadryl as a good strong and it has to mean you would not want to take that before a test because of sedation and it would slow your concentration well modafinil is a pro histamine ik drug and increases histamine therefore it should help with focus and concentration the problem is in terms of cost and coverage it is difficult medication to get it will be going to narak in about a year or so and hopefully we'll have better access to that medication its new counterpart versus provigil is now new vigil from the same company if we go up the line if somebody has a problem with the amphetamine category I have no hesitation switching over to the methylphenidate category as another whole category of medications and that often works well if you get too much stimulation from the amphetamines I might switch to methyl and ER CR or perhaps a concerta the metadata as I mentioned before is really more for your children because of its shorter action of duration of action and again you come up on the second line non stimulants the N DRI norepinephrine dopamine reuptake inhibitor that's your wellbutrin it's very mild in terms of its norepinephrine and dopamine reuptake inhibition but tends to still work very well if I have a patient with anxiety and depression and I'm going to treat that along with my ADHD I would always go with an SSRI if they have a great deal of anxiety because a medication like wellbutrin because it increases norepinephrine and dopamine will tend to cause increase anxiety so once they're on an SSRI and perhaps once they're on a benzodiazepine like klonopin at bedtime if I need something further then I'll add the wellbutrin which works very quickly for depression as a primary problem so you want to know and that's part of the reason why this algorithm starts with is it an anxiety disorder or is it a depressive disorder when you have an anxiety disorder you always want to start your medications low and gradually build up in great part because patients with anxiety disorders tend to get worse when you treat them initially especially if the dose of medicine is too high and the reason is that they have a great deal of sensitivity not only to the outside world but to their inside and their body and so anything that disrupts their own concentration focus their own ability to feel comfortable inside often triggers a whole host of side effects and very often they stop the medication early so that's another aspect of dealing with the the consequences of ADHD if I see a patient that has combined ADHD and bipolar disorder combined this is much more difficult type of patient you may see these in childhood they're not your simple ADHD patient who you put on some stimulant and you put on a small amount SSRI and maybe a little benzodiazepine at night these are patients that have a great deal of irritability and destructive capacity for the family they often create a great deal of anger hostility they are very frustrating to everyone around at home to friends they're often isolated because others can't get along with them they're difficult in school in primary care psychiatry I take on a lot of these patients because they're difficult to treat and often there's not a lot of places for these patients to go at least they've tried many different sources the psychiatrist can do a good job but if you think of a child or adolescent who's told we want you to see your primary care physician we want you to see a psychiatrist we want you to see a counselor they are going to put up quite a fuss because they don't see themselves as being quote crazy and they want to be like all the rest of the friends so going to a psychiatrist and a counselor is not the direction they want to go that's the reason I started years ago getting involved with the children with ADHD and bipolar even if you decide not to treat however it's best that if you could identify these as ADHD patients that are out of the ordinary and get them to a psychiatrist for evaluation that's often helpful because this is a in a sense of Beast on its own and very often when you get into the oppositional defiant disorder the the problem with dealing with these children you have to go to another level of medication which are often your anticonvulsant medications like depakote or lamictal you may have to add in a typical agent like seroquel or abilify and you're going to be on a variety of complex medications not saying that you can't but it does take additional work and I would say you really want to try to understand the medications and understand the conditions before you delve into this area this is a very rewarding area of my practice because when you deal with children and adolescents at this point if you catch them at 8 9 10 11 12 before the adolescent years when the sex steroids kick in and the bipolar component gets much worse you'll have a considerable impact on the patient and their family and the reason I say that is that in my practice on a regular basis I have physicians coming up to me and saying I have a question about this 17 or 18 year old who is in the practice who is creating absolute havoc with me with a family with school they're taking drugs they're ready to go to jail what can I do now to help them and I say what you need to do is turn back the clock to when they were about 10 or 11 12 and that's when you wanted to catch them because they're gonna be much more compliant they'll start medications and some of the best things in life are things that never happen which means when they don't get into the substance abuse and that I don't care anymore and wanting to be out with their friends and not showing up at night and taking the car these are all the issues that you're going to have to face when they're 17 18 that's part of the reason I come on to a program like this because for me the children the preteens and the early teens is the place to go in order to prevent these disasters all you have to do is read the newspaper listen to the news and look at the late teens early 20s as you just saw in Arizona same kind of scenario when you pick up the kids early you don't have the problems later and I have a whole host of children now becoming young adults that I've been seen now for 14 years here at UCD and are turning out to be fantastic people one of the nice parts of a DD you can tell the patient and the family is that when you treat the downside of the condition the problem with focus concentration memory when you help the lack of self-esteem the depression anxiety goes away they feel good about themselves they turn out to be wonderful adults these people are extremely creative likeable they often play music they play musical instruments and when they do one of my screening question that I always ask is do you play guitar and why in asking over the last 20 years you'll see that for the kids that that are ADHD that have this condition when they play a musical instrument 90 percent play guitar there may be no particular good reason but I follow this and I've seen this over and over I think they have a creativity that they like to write music they write poetry I have the kids bring in to my office and even the young adults the work that they've done and it is amazing the kind of drawing artwork the story writing the poetry so if you can let parents know that as they control this condition they are going to unleash a wonderful person with great deal of creativity and likability into society the child gets better and the adult gives gets a lot of relief knowing that their child is not going to end up in jail could believe me I've worked with the kids that have headed into jail and it's not much fun now is ADHD a correct name for this condition attention deficit hyperactivity disorder and Stephanie my nurses shake your head no which I've told her is their right answer attention deficit is not really the correct answer for this is not the correct terminology we all have problems with our attention we all forget things we all lose our keys we all find that we procrastinate at times so it's really more than these people of attention inconsistency in the attention inconsistency what we're looking at is that when you like something and have fun at it you can concentrate and focus on that when you don't like it when it's dry and boring the stuff that's often in school unfortunately that's when kids minds wander so if they sit in front of video games then and they concentrate and are focusing that doesn't mean that they have good attention that means because it's high-energy they will go for that kind of energy because they can focus in on it it's the dry boring again the schoolwork that they can't handle some of these kids have learning disabilities many don't if you get them on board with medication then the attention inconsistency really becomes more of attention focused as sustained attention not all kids have the hyperactivity either you'll see in many of the girls they will have no hyperactivity they sit quietly and they daydream and because of that they are lost in school and often not found out until the work gets harder and harder and many of the kids could answer many of the questions early on so they're not picked up for a few years and I have a number of teenagers who have done well until the work has gotten sufficiently hard that then they have the dip culty so again attention difficulty is really attention not a deficit it's an inconsistency and not all are hyperactive and is it a disorder well it depends if it's a problem to the patient and the family around them that's when it becomes a disorder and remember there's a great crossover between ADHD and OCD so you may see obsessive-compulsive disorder or features in these children as well and that's how many compensate I'm leaving you in the last minute or so with the names of some of the medications you have the reuptake inhibitors and I like the slow doe stimulants because they are more sustained and here you have names on the slow doe stimulants the conservative the metadata on the right side Ritalin they tirana dexedrine adderall xr and vyvanse as I mentioned earlier and the pulsatile stimulants the dexedrine adderall ritalin these are the shorter acting that you can use if you need to now that they're generic and very inexpensive most families can afford these I always am very careful the kids and adolescents I always make sure I see back initially once a month and at the latest every three months I will never give children adolescents or their parents six months to a year at a time because part of what we need to do is counsel at the same time and that's what occurs with each of the follow ups the adolescents never come in by themselves they always have a parent because children with ADHD often do not have a good insight and because they don't they need somebody objectively giving me information as well for verification of what they're saying on the norepinephrine transport inhibitors you see names on the right side we've talked about if you're in primary care medicine I'm sure you've seen the straight arrow wellbutrin effexor cymbalta pristiq is the long-acting effexor Sevilla which is now being used for fibromyalgia and not necessary for antidepressant and it is a strong norepinephrine reuptake inhibitor or prama and pamela are your older medications others I mentioned the Intuniv which is your long-acting guanfacine which is helpful for ADHD as well as the oppositional defiant disorder and our older medicine cata press so thank you for your attention and I would say both your selective attention and sustained attention so I thank you for your time and your attention if anything else comes up I'd be glad to hear from you you

Channel: University of California Television (UCTV)

Views: 27,239

Keywords: ADHD, ADD

Id: jGurE-BGfNk

Length: 52min 41sec (3161 seconds)

Published: Thu May 26 2011