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28.01.2015
There is often an overlap between clients with PAW and ADD with a set of commonly shared symptoms.
Answer: Attention deficit hyperactivity disorder (ADHD) is a particular condition that affects one’s behaviour or development. If stimulants are not providing the desired effect or if the side-effects are too unpleasant the medical professional may opt to administer a non-stimulant alternative. Stimulants are normally considered intoxicants and fall into the category of prohibition for recreational use in the Islamic view.
In Practical Laws of Islam, Sayyid Khamenei was asked “Is it permissible to use narcotic drugs for the treatment of diseases? The determination of the treatment or recovery being attributed to a certain drug falls on the shoulders of the trustworthy physician.
Symptoms begin prior to age 7 years, last at least six months and occur in two or more different environments (ex: home and school).
As part of the assessment of a child who presents with ADHD symptoms, it is important to rule out other possible causes such as head trauma, lead poisoning, neurological disorders and medication side effects. Rating Scales used in the assessment of children with ADHD symptoms include the Diagnostic Interview Schedule for Children, Child Behavior Checklist Parent and Teacher versions, Conner's Parent and Teacher Scales, Social Skills Rating System, and The Behavior Rating Inventory of Executive Functioning. It is worth noting that a low concentration of norepinephrine in the right dorsal and orbital regions of the prefrontal cortex are thought to account for many of the symptoms of ADHD. Attention Deficit Hyperactivity Disorder has a tendency to co-exist with other psychiatric diagnoses. Other comorbid diagnoses with ADHD are anxiety disorder (27 - 30 %), depression (15 - 30%) and tic disorders. Family aggregation studies, adoption studies and twin studies have shown some evidence of a genetic vulnerability for increased risk of the development of ADHD.
In 1996 the National Institute of Mental Health (NIMH) conducted a collaboative multisite multimodal treatment study of children with ADHD (the MTA Study). Outcomes were assessed in multiple domains and included the core symptoms of ADHD co-occuring problems in social skills, parent-child relations, oppositional defiant behavior, anxiety and academic achievement. The most common FDA approved medications used for the treatment of ADHD are the stimulants. Methylphenidate (Ritalin, Focalin, Methylin, Ritalin SR, Metadate ER, Metadate CD, Ritalin LA, Concerta, Focalin XR, Ritalin Patch) inhibits the reuptake of dopamine and norepinephrine through inhibition of the dopamine transporter system. The amphetamines (Dexadrine, Dextrostat, dexadrine spansules) diffuse into storage vessicles and cause the release of dopamine to the cytoplasm and blocks reuptake into the vessicle. Atomoxetine (Strattera) is a non stimulant medication that works by blocking the norepinephrine pump on the presynaptic membrane which increases the availability of intrasynaptic norepinephrine.
Antidepressant medications as a class, are used as "second line" treatment for the ADHD disorders.
Antihypertensives used for the treatment of ADHD are clonidine (Catapress) and guanfacine (Tenex). In rare cases other medications are used to treat ADHD including atypical neuroleptics, modafinil (Provigil), MAOI inhibitors (selegiline) and cholinergic enhancing medications (Donazepil and Tacrine). The MTA study results indicated that individual psychotherapy although useful, is most efficacious when combined with a medication intervention. Family therapy with ADHD children can help educate family members about the disorder amd facilitate effective ways of communicating behavioral expectations from the child. Martin, Andres MD, MPH, Bostic Jeff MD, EdD Child and Adolescent Psychiatric Clinics of North America Psychopharmacology. Steiner, Hans, Editor Handbook of Mental Health Interventions in Children and Adolescents - An Integrated Development Approach. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, Washington, DC, American Psychiatric Association, 2000.
Given the growing cost of college and the serious economic problems facing many families, these aborted college experiences create a significant financial burden, not to mention an emotional toll, on both students and parents. Transition planning, however, can make a big difference in helping teenagers with ADHD be ready for what lies ahead in college.
Gaining a fuller understanding of ADHD and its ramifications are important factors in its successful management. Adolescents with ADHD need to be encouraged to spend the time they have left before going off to college to work on these areas. Only one-third of college students who received special education services in high school seek such formal accommodations in college.
Over the last decade, several medications have been approved that make the treatment of ADHD easier and more effective.
Young adults on stimulant medications, particularly those living in dormitory or other communal settings, need to be reminded about several issues regarding these medications. In addition, it is important that patients understand that their medication is a controlled substance. As students with ADHD pursue their college careers, they must do so in environments that are less structured and supportive than the ones they experienced in high school. The overall message of this article is one that urges pediatricians to hold deliberative discussions with college-bound patients with ADHD as early as possible in the college transition process. Subscribe to Contemporary Pediatrics to get monthly clinical advice for today's pediatrician. All comments must follow the ModernMedicine Network community rules and terms of use, and will be moderated. Are you aware of the newly released CDC Guideline for Prescribing Opioids for Chronic Pain? Hi, Laurie Dupar here from Coaching for ADHD.  After years of working with clients who were unsure as to whether or not their ADHD medications were “working”, I created this ADHD Medication Log. By daily tracking the type, dose, frequency, positive and negative side effects of ADHD medications, you and your prescriber will be able to have a clearer idea if this is the right medication for you. As a bonus, you’ll also enjoy a complimentary subscription to my newsletter, New Perspectives, which is filled with valuable information, tips, strategies and resources for people with ADHD.
To download the ADHD Medication Log, enter your name and email address in the form below for FREE, INSTANT ACCESS. Medications known as stimulants have long been employed in the treatment of Attention Deficit Hyperactivity Disorder.
Medications usually used to treat ADHD improve the availability in the synapse of two neurotransmitters, dopamine and norepinephrine.
According to the AAP Treatment Guidelines, at least 80% of children will respond to one of the stimulants if they are tried in a systematic way. A new medication came on the market that appears to be of value to children who do not have a favorable response to stimulants. Stimulants are generally considered safe medications, with few contraindications to their use. Patients treated with medication for ADHD should have their height and weight monitored throughout treatment. On December 17, 2004, the FDA required a warning be added to atomoxetine because of reports that two patients (an adult and child) developed severe liver disease (both patients recovered).
In September of 2005, the FDA also issued an alert regarding suicidal thinking with atomoxetine in children and adolescents (Food and Drug Administration, 2005).
Recent research on the utilization of Straterra® (atomoxetine) as compared to stimulants found that children who start on Stratterra were 4.2 times more likely to change their therapy than children who started on stimulants.
The information presented above is for informational purposes only and does not take the place of advice from your child’s physician. National Institute of Mental Health, Attention Deficit Hyperactivity Disorder 2006 (rev) NIH Publication No.
David Smith reported on study of adolescent substance abusers that seemed to indicate the appropriate medication for severe ADD in adolescents prevents the abuse of other substances for the purpose of medicating ADD symptoms.


That means, a non ADHD patient would not be able to take this medicine in order to get high.
Impulsivity can manifest in a variety of ways - the most typical are blurting out answers in the classroom setting, having difficulty waiting during turn taking activities and intrusive with others during conversations. The symptoms must impair functioning in academic, social or occupational activities and must be excessive for the developmental level of the child to fit criteria for making the diagnosis. During the summer of 2005 case reports were disclosed which showed sudden cardiac death in 15 children being treated with Adderall products in the United Kingdom. Attention Deficit Hyperactivity Disease - A Handbook for Diagnosis and Treatment 3rd Edition. Students with ADHD often find the transition to college difficult because they were not prepared to advocate for themselves and to meet the increased academic expectations at college.
Parents are now insisting that students maximize the educational opportunities made possible by their financial sacrifice. Ironically, adolescents’ specific high school experiences may contribute to the difficulty. The treating pediatrician can play a significant role in assisting patients with ADHD to ensure that this transition goes smoothly.
Although the parents of patients with ADHD may have pursued this information for their children in the past, as young adults their children will need to take responsibility for their disorder and find out as much as they can. The transition from attending high school and living at home to starting college or university studies while living away from home is among the most challenging of transitions for many students; however, it is especially challenging for young adults with ADHD. Sometimes that means helping their parents see the benefits of letting go and thus allowing their teenagers to learn to function on their own.
Students with ADHD have little to no experience in handling the more difficult coursework and the freedom and responsibilities they will encounter at college. If the college they have chosen has a well-established disabilities program, and the staff is aware of and has sensitized the faculty to the needs of students with ADHD, students should have little trouble receiving appropriate accommodations. Difficulties with time management and planning often interfere with the best intentions of college students with ADHD. Now is the time for pediatricians and their college-bound patients with ADHD to work together to develop a medication regimen that will lead to a practical daily schedule.
These newer medications are all longer-acting preparations in a variety of formulations and delivery systems (Table). First, they should be cautioned not to give or sell any of their ADHD medications to their friends or to others who ask for it. Under federal law, ADHD medications are schedule II substances, and even giving these medications away can result in a drug distribution charge. This opportunity for growth and maturation is important, leading students with ADHD to work on their own to achieve balance and structure in their lives.
These discussions should encourage self-determination and the acquisition of independent living skills. She is a founding board member of the EDGE Foundation and a paid consultant and speaker for Noven and Shire Pharmaceuticals. ModernMedicine reserves the right to use the comments we receive, in whole or in part,in any medium.
Andrew Adesman, Chief of Developmental & Behavioral Pediatrics at the Steven and Alexandra Cohen Children's Medical Center of New York (CCMCNY), part of the North Shore-LIJ Health System.
I encourage you to print out the ADHD medication log and make copies for your personal use and share this with your individual prescriber so you can better partner with them in finding the right ADHD medication for you! Specific neurotransmitters (brain chemicals) are necessary to carry a nerve impulse (message) along a neuropathway (circuit).
Clinicians should begin with a low dose of medication and titrate upward because of the marked individual variability in the dose-response relationship. Children who fail to show positive effects or who experience intolerable side effects on one stimulant medication should be tried on another of the recommended stimulant medications. Side effects occur early in treatment and tend to be mild and short-lived.Ref The most common side effects are decreased appetite, stomachache or headache, delayed sleep onset, jitteriness, or social withdrawal. If the patient has a change in height or weight that crosses 2 percentile lines, this suggests an aberrant growth trajectory. Food and Drug Administration (FDA) directed the manufacturers of all drug products approved for the treatment of Attention Deficit Hyperactivity Disorder (ADHD) to develop Patient Medication Guides to alert patients to possible cardiovascular risks and risks of adverse psychiatric symptoms associated with the medicines, and to advise them of precautions that can be taken.
In twelve controlled trials involving 1,357 patients on atomoxetine and 851 on placebo, the average risk of suicidal thinking was 4 per 1,000 in the atomoxetine-treated group vs. Although there is controversy regarding, it is a medically and psychologically accepted behavioural disorder.
Stimulants work in treating the patent 70-80 percent of the time by causing quick and dramatic improvements in behaviour. Students from families who are struggling to make tuition payments cannot afford the luxury of reduced course loads or taking additional semesters to graduate. Most teenagers today lead structured lives and get very little practice making decisions about how to manage their time and life in general. By having a detailed discussion with their teenaged patients on how ADHD can affect them at college and what they can do about it, pediatricians can help these patients take the first steps on the road to success. College is dramatically different from high school with no adults to prod a teenager and help structure his or her life. These students will inevitably discover that their last-minute approach to preparing for tests or writing papers will not work at college.
By having a discussion that includes questions about each patient’s strengths and weaknesses, preferred learning style, passions, and hopes for the future, pediatricians can help these students assess their capabilities and ascertain where they will need support.
As a result of the problems they have with setting and achieving their goals, overall daily living tasks and academic achievement may suffer. Pediatricians of these patients may need to point out that ADHD affects not only the students’ academic performance but also their relationships, emotions, and day-to-day activities such as eating, sleeping, and getting enough exercise.
Encouraging patients to take their medication consistently so that it will be effective for studying and reading assignments is often critical to a successful transition. Such once-a-day preparations provide the individual with ADHD a means of reducing symptoms throughout the day and into the early evening, while eliminating the need for a multiple-dose regimen that is difficult for those with ADHD to remember.
Not only does this reduce the amount of medication that they have for their own personal use, but it could also endanger the health of the other person. Further, if patients use up their medication more quickly than prescribed or lose it, they will not be able to receive a new prescription until the end date of the current prescription. Discussing ways to maintain good emotional and mental health, including how to deal with stress and how to get the emotional support through individual or group therapy or attending peer support groups on campus, is critical. By engaging college-bound students in this process, pediatricians are providing them the greatest opportunity to achieve success in college as well as in life. Identifying and treating attention deficit hyperactivity disorder: a resource for school and home. The post-high school outcomes of youth with disabilities up to 4 years after high school: a report from the National Longitudinal Transition Study-2 (NLTS2).
The ADHD Parent Care Package: Support and Encouragement for Parents of Teens and Young Adults with ADHD. A number of neuro-imaging studies have shown that the brain functioning of ADHD patients does improve and appears to be more like the normal group after they have taken their prescribed medication.
When a neurotransmitter is not fully available, a message may be stopped short of its intended destination. However, with the prevalence of the disorder estimated to be at 5.0%, one could make a case for under prescribing. They actually improve functioning in various areas of the brain involved with attention, concentration and self-control.
The first dose that a child’s symptoms respond to may not be the best dose to improve function.


Children who fail 2 stimulant medications can be tried on a third type or formulation of stimulant medication for the same reason.
Although the mechanism of action is not known, guanfacine, the active ingredient in INTUNIV, is thought to selectively stimulate alpha-2A adrenoreceptors in the prefrontal cortex. Most of these symptoms can be successfully managed through adjustments in the dosage or schedule of medication. In these cases, a drug holiday should be considered, if return of symptoms during weekends or summers does not lead to marked impairment of functioning. Recently the American Heart Association (AHA) recommended routine electrocardiograms to be performed before prescribing stimulant medications to children and adolescents for the treatment of ADHD.
Patients who develop jaundice, dark urine, or other symptoms of hepatic disease should discontinue atomoxetine. But, the disorder has to be diagnosed by a trustworthy and competent medical professional, not a parent or family member, before medicine can be administered. Common stimulants that are used are: Adderall, Concerta, Dexadrine, Focalin, Metadate, Methylin, Ritalin, Vyvanse, Daytrana, and Quaillivant. Some colleges are now setting firmer time limits on how long a student may take to complete a degree. With this goal in mind, it is useful to discuss the following areas with teenaged patients with ADHD. Although many students with ADHD may relish this initial taste of freedom, many quickly find themselves floundering and experience great difficulty managing their daily routines.
This is a lot to consider for such patients, but to foster success at the college level, these teenagers with ADHD will need to address their disorder and begin to take charge of their own care. It may take some time to get a new prescription and have it filled, so students should be reminded to plan accordingly, especially around exam time.
Given the trusting relationship that exists with these patients, pediatricians are likely in the best position to impart the critical information needed to ensure their successful transition to college. Beginning postsecondary students in 2001 by disability status and learning disability status [CD-ROM].
The Drug Digest provides an excellent synopsis on the use of stimulants with children and adults. When this happens, the function regulated by that circuit may not work as well as it should.
Most authorities believe that stimulants are both over and under prescribed based diagnostic and patient compliance issues so that some children are receiving medication they do not need while others are not receiving this necessary treatment for their condition. Over 200 well controlled studies have shown that these medications are the safest and most effective psychiatric medications. Stimulation of the postsynaptic alpha-2A receptors is thought to strengthen working memory, reduce susceptibility to distraction, improve attention regulation, improve behavioral inhibition, and enhance impulse control.
Approximately 15% to 30% of children experience motor tics, most of which are transient, while on stimulant medications. The common side-effects that ADHD patients have from these medications are: decreased appetite, weight loss, sleep problems, headaches, jitteriness. Instead of encouraging the 5-year plan that a number of students have adopted, some colleges are pushing for the 4-year, 8-semester plan, an approach not allowing for as many stops and starts as in the past. Most teenagers have well-meaning parents who have established rules for what needs to happen when. These differences are at odds with the core symptoms seen in students with ADHD, particularly poor executive functioning, which affects both time management and organizational skills. In addition to lacking the important time management and study skills needed at college, these students have no experience needing or asking for help.
The latter includes the use of medication, meaning that they need to become more knowledgeable about their medication and its effects. Finally, pediatricians should remind patients that, by law, these medications need to be kept in the original bottles and suggest that students carry their medications with them at all times to prevent theft. Pediatricians can take this opportunity to reinforce the need for maintaining healthy habits.
For updates on new medications and warning about medications the FDA website is your best source of information. Failure to treat ADHD with medications may result in increased risk of substance abuse and decreased white matter volumes in the brain as well as poor academic achievement, low self-esteem, difficulty in a wide range of social situations, over reaction to change and frustrating circumstances and less likelihood of success as adults.
This strategy may require reducing the dose when a higher dose produces side effects or no further improvement. Primary care physicians most likely will consider referral to a child and adolescent psychiatrist at this point. It is important for the clinician to carefully balance the benefits of medication treatment with the risks of small reductions in height gain, which as of yet have not shown to be related to reductions in adult height. Here is the current position of the American Academy of Pediatrics (AAP) regarding the issue.
The protectiveness and anxiety of these parents may have led them at times to take over their child’s responsibilities and make things happen in an effort to have their teenager avoid stress and failure. College students face unlimited possibilities for how to spend their time, and may experience increased academic demands that most have not had in high school, even if they have taken advanced placement classes.
They often view these first academic problems as a sign of personal failure and end up in a cycle of hiding their mistakes from family members and friends. It is also important to discuss how taking medication might improve other aspects of daily life such as organization, time management, and relationships, in addition to academics. The best dose of medication for a given child is the one that leads to optimal effects with minimal side effects. Bupropion, tricyclic antidepressants (TCAs), and alpha-agonists are often used in the treatment of ADHD even though they are not approved by the FDA for this purpose. This risk is quite small, but it should be discussed with patients and family, and children should be monitored for the onset of suicidal thinking, particularly in the first few months of treatment. Add to this mix an irregular class schedule, professors who do not take attendance or assign and grade daily homework, only a few tests during the semester that cover hundreds of pages of reading, and complex long-term assignments that the student must have the self-discipline to complete. It is important to note that all professional guidelines call for medication to be used AFTER behavioral treatment has been tried first and that when medication is used it should be COMBINED with behavioral treatment.
The dosing schedules vary depending on target outcomes, although no consistent controlled studies compare different dosing schedules.
Although there is at least one double blind, randomized controlled trial for bupropion, and TCAs, the evidence base for these medications is far weaker than for the FDA-approved agents. The presence of tics before or during medical management of ADHD is not an absolute contraindication to the use of stimulant medications.Ref A review of 7 studies comparing stimulants with placebo or with other medications indicated no increase in tics in children treated with stimulants. Daily assignments, weekly tests, manageable reading assignments, few independent long-range assignments, and teachers who may encourage, direct, control, remind, prod, and sometimes even nag their students to perform all foster dependence. By highlighting the need for good executive functioning skills at college, the pediatrician can call attention to an area that has been found to be critical to academic success.
According to a study conducted at State University of New York at Buffalo, “combining behavior modification therapy with medication is the most effective way to improve the behavior of many ADHD children.
For example, if there is a need for relief of symptoms only during school, a 5-day schedule may be sufficient.
It is, therefore, not surprising that succeeding on their own at college is so challenging for adolescents. In advising these young patients with ADHD, the idea of working with a coach or academic or peer tutor can also be suggested, emphasizing how such personal support can help them achieve their goals.
In fact, when the two are combined, the study showed, the amount of medication required to achieve the same results as use of medication alone can be reduced by two-thirds”.



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