        
                    HISTORY OF ATTENTION DEFICIT DISORDER
        
        1900s     Still (England)
        
            Deficits in Inhibitory Volition, Moral Control, Sustained
        Attention.  Compared to children of same age.  Not related to
        upbringing, probably hereditary vs brain injury, males more
        than females 3:1.  Many of these childrens had tics (70 % of kids
        w/ TS, tics have ADHD).
        
        1917 Encephalitis epidemic, North America
        
             Researchers studied many survivors.  Significant
        behavioral/cognitive deficits.  Some of these kids demonstrated
        deficits in attention, impulse control and where hyperactive.  
        
        1930 - 1960s   Minimal Brain Dysfunction
        
             Many reports of behavioral/cognitive deficits in children
        with brain injury due to birth trauma, neurotoxins (lead), head
        injury, etc.  Some of these kids where ADHD, but many more with
        more serious neurological problems.  Nevertheless : Kids with
        distractibility/hyperactivity/impulsivity must be brain damaged
        in some way.
        
        1950s     Hyperkinesis
        
                  Hyperkinetic Impulse Disorder
        
        Still thought of as a type of brain damage syndrome.
        
        1960s     Hyperactive Child Syndrome
        
                  Emphasis on activity
        Not necessarily a result of brain injury.  Earned itself a place
        in the DSM II : Hyperkinetic Reaction of Childhood Associated
        with other neurobehavioral disorders, MR, etc.
        
        1970s     Attention Deficits
        
             Further understood that brain injury/damage not major cause
        Many studies that targeted attention as a primary problem/cause
        
        1980s     Further work on attention/impulsivity issues
        
                  DSM III and IIIR
        
             ADDH then ADHD.  Recognized attention deficit with and
        without hyperactivity
        
        1990s     Behavioral Disinhibition and Deficient Rule Governed    
                  Behavior.
        
             Deficit in attention may not adequately explain ADHD
        children's response to external stimuli. However, if behavioral
        dishinibition is thought of as the primary problem, this may
        adequately explain distractibility and impulsivity.
        
             Deficient Rule Governed Behavior. Consequences to behavior,
        rewards and/or punishment, are not regarded as important by the
        child with ADHD. Biological?
        
        Current Conceptualization
        
             Russel Barkley : ADHD may be "a primary deficit in
        behavioral or response inhibition, the ability to delay
        responses, or the tolerance for delay intervals within tasks."
        Based on Bronowski's theory of language and cognitive
        development.
        
                  - Separation of Affect
                  - Prolongation
                  - Internalization
                  - Reconstitution
        
        An Important Alternative Perception.    Hunter Concept
        
        
        ADHD  Diagnosis
        
        There is no one "test" for ADHD
        Many conditions can impair attention
        Evaluation must be multidisciplinary:
        
                  Medical
        
                       Comprehensive History Taking
                            Prenatal/Perinatal/Postnatal
                            Medical History
                            Developmental
                            Family
                            DSM IV Criteria for ADHD (and other NBDs?)
                       Complete Physical
                            Neurologic Evaluation
                            Growth
                       Additional Testing
                            Vision and Hearing (Complete Audiological if
                            ? CAP)
                            Blood Work - Thyroid EEG?
                            Cardiac Evaluation, EKG, etc. to evaluate     
                            potential med problems
                       Educational/Academic
        
                       Academic Performance
                       Questionnaires
                       Multidisciplinary Evaluation
                            IQ and Achievement Testing
        
                  Psychological/Social/Family
        
                       Psychological Evaluation
                       Family Issues
                       Differential Diagnosis
                            Other emotional/behavioral problems
                  Other
                       Comprehensive Developmental Evaluation
        
        
                                  ADHD
        
                            Important Issues
        
        Academic  
        
             Greater liklihood of grade retention, poor academic
        achievement and dropping out.  Often find themselves in trouble,
        disruptive.
        
        Social
        
        Making and keeping friends is difficult.  Frequently unable to
        communicate effectively with peers.  Often unable to participate
        in organized activities, ie sports, etc.  "Different" Family
        
             Takes greater share of attention, resources, etc. within the
        family ADHD issues can be devisive Self / Self Esteem.
             
             Problems in the above arenas can have profound effects on a
        child's sense of self worth and self esteem.
        
             Depression and other emotional problems.
        
          ADHD Treatment Issues
        
        Treatment must be MultiModal!
        
                  Psycho-Educational Counseling
        
                  Medication
        
                  Behavior Management
        
                  School Based Intervention
        
                  Family Therapy
        
                  Social Competence Training
        
                       ADHD MEDICATIONS     
        
        Medications
        
        
        Stimulants
        
             Ritalin (methylphenidate)
             Cylert (pemoline)
             Dexadrine (d-amphetamine)
        
        Catpress (clonidine)
        
        Tricyclic Antidepressants (TCAs)
        
             Tofranil (imipramine)
             Norpramine (desipramine)
        
        Selective Serotonin Reuptake Inhibitors
         
             Prozac (fluoxetine)
             Paxil (paroxetine)
             Zoloft (sertraline)
        
        Others
        
             Wellbutrin (buproprion)
             Buspar (buspirone)
             ??????
        
        Stimulants
        
        
        General Comments 
        
             Most used type of medication in pediatric psychopharmacology
             Benefits of stimulant therapy can extend into adulthood.
        
             75% of ADHD children will show improvement in some or all of
        the following areas:
        
                  Motor behavior
                  Cognitive effects
                  Motivation
                  Academic achievement
                  Interpersonal skills
                  
             No set dosages
        
                  Medication trials
                       Questionnaires
                  Feedback from school, other outside activities
                  Observation at home during weekends, holidays, etc.
        
             Drug holidays
                  
                  Highly individual
                  Should be flexible
        
             Side effects
        
                  Loss of appetite
                  Insomnia
                  Irritability
                  Abdominal pain
                  Behavioral rebound
                  Tics
                  Depression
                  Tachycardia
                  Liver abnormalities : Cylert (pemoline) only.
                  
             Suspected and/or unsubstantiated side effects
        
                  Increased use of recreational drugs - NO!
                  Reduced seizure thresholds - Not proven.
                  Growth retardation - More an indirect side effect as    
                  realized by anorexia (?)
        
             Toxicity
        
                  "Spaced Out"  "Zombie"
                  Irritable, Emotionally Labile
        
        Ritalin (methylphenidate)
        
             Schedule II drug
             
                  Shortage in 1993 because of tight regulation and
        bureaucratic foul-up.  Cannot phone in Rx, No refills
        
             Available in regular and slow release
        
             Available Dosages :
        
                  Ritalin : 5, 10, 20 milligrams
                  Ritalin SR :  20 milligrams
        
             Generic methylphenidate 
        
                  Less expensive
                  ?? As effective/predictable ??
        
             Usually the first drug tried for ADHD
        
                  Most effective
                  Well tolerated
                  Easily titrated
                  Works immediately 
        
             Short half life (3-5 hours)
        
                  Often dosed 3-4 times a day
                  Flexibility of dosing
        
        Dexedrine (d-amphetamine)
        
             Similar to other stimulants
        
             Schedule II
        
             Available dosages
        
                  Dexedrine tablets : 5, 10 milligrams (10 mg generic     
                                      only)
                  Dexedrine elixer : 5 mg/5ml (generic)
                  Dexedrine spansules : 5, 10, 15 milligrams (brand name  
                                        only)
        
             FDA approved down to 3 y.o.
        
             Longer half life (4-6 hours)
        
                  May still need multiple daily doses     
        
        Cylert (pemoline)
        
             Similar to other stimulants
        
             Schedule IV
        
                  Refills allowed
                  May phone in Rx
        
             Available dosages
        
                  Cylert tablets : 18.75, 37.5, 75 milligrams
                  Cylert chewables : 37.5 milligrams
        
             Longer half life (8+hours)
        
                  Once a day dose (reduced stigma)
                  Takes longer to achieve full benefit
                  Not as flexible as other stimulants
        
             Liver toxicity in approx 1% of patients
        
                  Usually reversible
                  Needs routine blood work 
        
        Catapress (clonidine)
        
             Antihypertensive, also used in alcohol, drug and nicotine
        withdrawal.  Has been used to reduce tics in Tourette's and more
        recently to control hyperarousal and aggression in manic patients
        Recently has gained broad support in use for ADHD.  Particularly
        useful in the very aggressive, impulsive, hostile, hyperactive
        ADHD children.  Does not increase attention to the extent that
        stimulants do
        
        Side effects :
        
             Sedation
             Depression
             Hypotension
             Headache
             Dizziness, N & V
             Stomach ache
        
        Needs cardiovascular evaluation before use (EKG, etc.). Monitor
        BP after starting clonidine
        
        Need to titrate dose slowly to minimize side effects
        
             May be difficult, small tablets.
                  ?pharmacy prepared elixir
                  patch
        
        Available dosages
        
             Catapress tablets : 0.1, 0.2, 0.3 mg
             Catapress TTS (patch) : 0.1mg/day, 0.2mg/day, 0.3mg/day
        
        No drug holidays - rebound hypotension. 
        
        Also used in combination with Ritalin
        
             Help with aggressivity
             ? Help with Ritalin rebound
        
        Tricyclic Antidepressants
        
        Most commonly used TCA's in ADHD
        
             Tofranil (imipramine)
             Norpramin (desipramine)
        
        Has been demonstrated to improve Sx of ADHD
        
        Used in older children 
        
             Needs good cardiovascular evaluation
             Baseline and follow-up EKGs
        
        May be particularly helpful for those with depression/anxiety
        
        Side effects 
        
             dry mouth
             gastric distress
             constipation
             urinary retention
             fatigue
        
        Start with lower doses than used in depression, adjust slowly
        upward
        
        Others:
        
             SSRIs
        
                  Prozac, Zoloft & Paxil
                  Exciting new class of drugs
                  Being studied for ADHD in adults and children
                  Low incidence of side effects
        
             Wellbutrin (buproprion)
        
                  Has been studied for adult ADHD
                  Effective
        
             Buspar (buspirone)
        
             Benzodiazapenesn.
                  Growth retardation - More an indirect side effect as    
               realized by individuals.
