Presentation by Professor Fiona McNicholas Understanding and Managing ADHD in Children and Adolescents an HADD and Lucena Parent Evening 20 September 2011 as part of ADHD Awareness Week 2011

4. Development of ADHD as a clinical entity 1950 1980 1968 1970 1987 1994 1937 Minimal Brain Damage/ dysfunction Attention Deficit/Hyperactivity Disorder ( DSM-III-R ) ADHD ( DSM-IV ) Hyperactive Child Syndrome 1930 1902 1 st Clinical Description by Still 2010 DSM V? Gender Age/ onset STROOP TEST Hyperkinetic Reaction of Childhood ( DSM-II ) ADD ± HA ( DSM-III ) Adult ADHD Studied V. Douglas

5. Development of treatments in ADHD 1950 1980 1968 1970 1994 1937 Efficacy of Amphetamine (Bradley) 1930 1902 Antipsychotics 1954 1 st published study on MPH 1962-1993 250 reviews 3000 articles on stimulant effects 1966 161 RCT Long acting meds Ritalin LA Concerta Atomoxetine Equasym 2011 Newer Drugs Guanfacine

6. ADHD Inattention Hyperactivity Impulsivity

10. STROOP -read the words (Skill) RED YELLOW GREEN BLUE GREEN RED BLUE YELLOW BLUE GREEN YELLOW RED YELLOW RED GREEN BLUE RED YELLOW GREEN BLUE GREEN RED BLUE YELLOW

11. STROOP -name the colour of the words (Attention) RED YELLOW GREEN BLUE GREEN RED BLUE YELLOW BLUE GREEN YELLOW RED YELLOW RED GREEN BLUE RED YELLOW GREEN BLUE GREEN RED BLUE YELLOW

16. Co-morbid Disorders Oppositional Defiant Disorder 40% Tics 11% Conduct Disorder 14% ADHD alone 31% Anxiety Disorder 34% Mood Disorders 4% MTA Cooperative Group. Arch Gen Psychiatry 1999; 56:1088–1096

23. Functional Impairment in Patients with ADHD Compared to Those Without 35% 40% 16% 50% 30% 53% 52% Biederman et al. Am J Psych 1995.

25. Treatment

28. Stimulants raise dopamine levels Stimulants raise dopamine levels MPH/ Amphetamines Noradrenergic agents can reduce arousal Clonidine / Guanfacine TCAs, venlafaxine, bupropion Atomoxetine (Raises fromtal DOPA also by inh NA transporter)

31. General Behaviour Management

36. It is how you interpret it…

37. Guidelines

39. HADD

40. Web Toolkits Simple road maps to help parents/carers, children and teachers find the right tools at the right time Discussion guides to structure discussions at critical points in the child’s schooling Downloadable tools to help provide a consistent approach to supporting a child, and work in effective partnership. http://www.adhdandyou.ie

43. The End

44. Medical Costs Are Greater in Children With ADHD Leibson CL, et al. JAMA . 2001;285:60-66. 9 year FU of >4000 children 26% 41% 81% 18% 33% 74% 0 10 20 30 40 50 60 70 80 90 Inpatient hospital admission Outpatient hospital admission Emergency admission ADHD (n=309) Non-ADHD (n=3810) P <0.001 P <0.006 P <0.005 $4306 $1944 $0 $500 $1000 $1500 $2000 $2500 $3000 $3500 $4000 $4500 ADHD Non-ADHD Overall medical costs 1987 to 1995 % total cohort Medical cost over 9 years (1995 national avg. dollars) N=4119 P <0.001

46. Mechanism of Action of Stimulants v v Storage vesicle DA Transporter Cytoplasmic DA Methylphenidate blocks reuptake Presynaptic Neurone Synapse Wilens T, Spencer TJ. Handbook of Substance Abuse: Neurobehavioral Pharmacology. 1998;501-513. Amphetamine blocks reuptake Amphetamine blocks