Update on Treating ADHD PDF
Preview Update on Treating ADHD
Update on Treating ADHD ASCP Annual Meeting Miami Beach, FL May 31, 2018 Anthony L. Rostain, M.D., M.A Professor of Psychiatry and Pediatrics University of Pennsylvania Perelman School of Medicine Co-Director, Developmental Neuropsychiatry Program The Children’s Hospital of Philadelphia Medical Director, Adult ADHD Treatment & Research Program PENN Behavioral Health Disclosures Book royalties (Routledge/Taylor Francis Group, St. Martin’s Press) • Scientific advisory board honoraria (Shire, Ironshore, Arbor) • Consultant honoraria for MLB, NFL, SUNY/Upstate (AHRQ grant) • CME presentations for WebMD, NACE, Global Medical Education, • American Psychiatric Association Learning Objectives To review • Current understandings about the neurobiology of ADHD • Mechanisms of action of commonly prescribed ADHD medications • Practical tips for prescribing and monitoring medications • New medication options currently under investigation Neurobiology of ADHD Symptoms Predominantly Predominantly ADHD Combined inattentive hyperactive–impulsive Executive Function Motivation Basic Working Behavioral Delay Processes Reinforcement memory inhibition aversion PFC Basal ganglia Cerebellum Neural Mechanisms Noradrenalin Dopamine Serotonin Genes DBH HTR1B DAT1 D4 D5 SER T SNAP-25 PFC = prefrontal cortex. Tripp G, et al. Neuropharmacology. 2009;57(7-8):579-589. n Behavioral disinhibition, emotional ability o Full expression of Inattention persists and hyperactive– and emergence of diagnosis in preschool it ADHD, psychiatric ai impulsive symptoms wane years t i comorbidity, school failure, n i peer rejection g Prodrome: hyperactivity; and speech, n and neurocognitive ik Substance abuse, low self-esteem language and motor coordination o dysfunction m and social disability problems S In utero Childhood Adolescence Adulthood Genetic Psychosocial influences, chaotic family environments, peer influences and mismatch with predisposition school and/or work environments Different genetic risk factors affect the course of ADHD at different stages of the lifespan Fetal exposures and epigenetic changes Frontal–subcortical–cerebellar dysfunction via structural and functional brain abnormalities and downregulation of catecholamine systems that regulate attention, reward, executive control and motor functions Persistence of cortical thickness, Clinical Progression Etiology Pathophysiology default-mode network and white matter tract abnormalities Faraone SV, et al. Nat Rev Dis Primers. 2015;1:15020. Schematic representation of functional circuits involved in the pathophysiology of ADHD Purper-Ouakil D, et al. Pediatr Res. 2011;69(5 Pt 2):69R-76R. Regulation of Attention and Emotion Arnsten AF, et al. J Am Acad Child Adolesc Psychiatry. 2012;51(4):356-367. Regulation of Attention and Emotion Arnsten AF, et al. J Am Acad Child Adolesc Psychiatry. 2012;51(4):356-367. The Prefrontal Cortex Requires a Proper Level of Catecholamines for Optimal Function Guided attention and responses Focused, organized and flexible (eg, Optimally treated ADHD) NE a 2A Moderate D 1 Unguided attention / responses Misguided attention / responses Distracted, poor impulse control Mental inflexibility, stimulus bound Too little NE a , b (eg, Untreated ADHD) (eg, Excessive dose of stimulant) 1 1 a /D Excess D 2A 1 1 Drowsy Alert Stressed Increasing Levels of Catecholamine Release Arnsten AF. J Pediatr. 2009;154(5):I-S43. Treatment Modalities for ADHD Educational / Workplace Interventions Psychosocial Medical Interventions Interventions Dulcan M. J Am Acad Child Adolesc Psychiatry. 1997;36(10 Suppl):85S-121S.
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