ADHD: Management

by Helen Farrell, MD

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    00:01 A couple of points about the treatment of ADHD are worth noting.

    00:05 So before prescribing medication for the patient with the ADHD, you might try a non-pharmacological approach. So things like behavioral modification, ask the patient to maintain a daily schedule, keep distractions to a minimum both at home and the classroom, provide specific and logical places for the child or even adult to complete their work and tasks, set small reachable goals for people to attain, and try rewarding positive behaviors. Also, be sure not to reinforce negative behaviors.

    00:40 Use a chart or check list to help keep the person on task, limit their choices so they don't become overwhelmed, find activities in which the child can be successful in doing, and use calm when you're disciplining. Also, try social skills training, and sometimes dietary modifications can help as well.

    01:00 Now when it comes to the pharmacotherapy there are two options, basically non-stimulant medication and stimulant medication.

    01:07 When you talk about two of the non-stimulant choices, atomoxetine and bupropion, now there are benefits to these being that there's a once a day dosing, they are non-addictive medications, and they are not controlled substances.

    01:21 These are of course originally founded as antidepressants but have been found to really boost concentration and focus in individuals with ADHD making them good options. Now, when it comes to their drawbacks there are a few.

    01:37 They may be less effective than traditional stimulant medications, they also can be accompanied by an increased risk for suicidal ideations, so you've to be very careful in the patient especially young child or a teen who's at all prone to moodiness and suicidal thoughts. They may take a lot of time to reach a steady state so when people are looking for a quick solution these medications can take over a month to really start working. Also it's not optimal to take a drug holiday when using one of these medicines. You really want someone to take it every day so that steady state can be reached whereas with stimulants you can actually do a drug holiday which can sometimes be desirable and make the medication even more effective over time.

    02:20 The other drawback to atomoxetine and buproprion is that it in fact can be pretty expensive for patients. You want to encourage the patient to take them with food to increase efficacy and also there may need to be dose adjustments when there's a drug-to-drug interaction in particular when other medications work at the cytochrome P450 2D6 enzyme.

    02:42 Now when it comes to stimulants there are both short acting and long acting choices.

    02:49 Some of the advantages of the short acting stimulant is that they've actually been very well studied and they're known to be efficacious.

    02:56 They're also cheap and widely available. They must be taken now 2-3 times a day which is a drawback and a disadvantage. It's multiple doses of medication throughout the day that can be hard to remember and keep on track with. The other thing is that short acting stimulants are very, very, addictive so that's another drawback to these medications and it really requires taking a thorough history from a patient and if the patient's a child involving the family in the care and making sure to continuously monitor for any problems and as the patient becomes older, a teen, adolescent, even young adult, really monitoring for substance abuse problems.

    03:36 Now long acting stimulants are also another good option. These can be delivered in a way in which there is a sustained pulse release. There are also a lot of options for these medications. They're not solely available in pillar capsule form but you can actually try doing a patch, you can deliver the medication in oral suspension that really helps especially with children who have trouble swallowing pills.

    04:02 You can also do sprinkles that are put on food and so forth.

    04:07 They usually require only once a day, maybe sometimes twice a day dosing but that really helps to enhance compliance when somebody doesn't have to take a medication multiple times a day. Some examples are Ritalin and Adderall, also Focalin, and worth noting newer drugs are being developed all the time.

    04:25 There's a new prodrug available that actually is a lower abuse potential because it's only once daily dosing. The drawback is of course with every advancement in new medication that comes along they are usually associated with a higher cost.

    04:39 So as a quick review of ADHD, both behavioral interventions that can be helpful to your patient and also some medication choices. Remember to consider non-stimulant and also stimulant choices and within the stimulant group there are short and long acting, something key to keep in mind.

    About the Lecture

    The lecture ADHD: Management by Helen Farrell, MD is from the course Mild and Major Neurocognitive Disorders. It contains the following chapters:

    • ADHD
    • Non-stimulant Choices
    • Stimulants

    Included Quiz Questions

    1. Atomoxetine
    2. Ritalin
    3. Adderall
    4. Alprazolam
    5. Focalin
    1. Big goals should be set to better motivate the patient.
    2. Maintaining a daily schedule
    3. Reducing distractions to the minimum
    4. Rewarding positive behavior
    5. Identifying unintentional reinforcement of negative behaviors
    1. Bupropion is more effective than stimulants.
    2. Bupropion increases the risk of suicidal ideation.
    3. Bupropion drug holidays are not an option.
    4. Bupropion is very expensive.
    5. Bupropion takes more time to reach steady states.
    1. They are cheap and available as generic options.
    2. They must be taken 2-3 times a day.
    3. They are also available in sustained pulse release forms.
    4. They are available as pills, patches, suspensions, and sprinkles.
    5. They have less addictive potential.

    Author of lecture ADHD: Management

     Helen Farrell, MD

    Helen Farrell, MD

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