 Well thanks Fred and thanks for the great work that you're doing at Clarity. What a great partner to have. Bear County deals with all the very very tough issues facing this community and one of those very very tough issues is what we're trying to do with respect to children that are getting in a bit of trouble. We have a detention center, we have a correctional system for juveniles, the psychiatry's department of the UT Health Science Center provides help for both of those places. We have a huge hospital system that Bear County is responsible for called University Hospital. It is a new building that we just built downtown, another million square foot building that we just built out in the Medical Center. The Department of Psychiatry, Child Psychiatry plays an important role with us because all of the pediatric services were transferred over to University Hospital just in the last year or so. So it's a key and critical part that Dr. Steven Pliskey in the school is doing for us and we're fortunate to have someone that has that experience in this field as well as the experience of some since 1986 serving on the with UT Health Science Center. We also have a children's court that plays a key role where neglected and abused children cases are handled and Dr. Pliskey and I were just talking that we turned so many kids. We I think the legal system becomes a monster after so much time and we're trying to sort out how can we do more at the front end on some of these difficult cases that end up spending all our money on a legal system and ends up throwing more and more kids into foster care and you're talking about mental problems they'll have that there as they toss from one family to the next and that system is overloaded. So we're struggling and Dr. Pliskey has agreed to help us sort of sort out. Should we be doing things in a different way and trying to reach some of these families earlier and trying to help the children earlier and trying to stabilize families rather than just grinding through a legal system which is eating up all of the money. So there's a lot of a lot of major issues to be facing for us and and we're delighted here to be here today to introduce Dr. Steven Pliskey. He's the chief of the Division of Child and Adolescent Psychiatry at the University of Texas. He's worked continuously at Clarity Child Guidance Center since 1983. He is currently served as the medical director of Clarity CGC outpatient psychiatry services. In this role he oversees the care of psychiatrists and their work with children with a wider range of problems. He's been a member of the faculty at UT Health Science Center since 1986. He's been involved in a way of different issues during that period of time from administrative to research to clinical and educational activities. He's done a great deal of research on attention deficit hyperactivity disorder and the related disorders associated with that. He currently currently uses functional magnetic imaging to try to understand the mechanics of the medication of ADHD. He's the author of Neuroscience of the Mental Health Clinician. He's been active in the American Academy of Child and Adolescent Psychiatry. And he has stated, I have felt a part of the Clarity Child Guidance Center since the day I arrived. Through Clarity we have reached children who would otherwise go without treatment. Nearly half the child and adolescent psychiatrists practicing in San Antonio have trained at Clarity through the partnership with UT Health Science Center. And he says, I am proud to be a part of the leadership of a caring institution. So Dr. Plisky, come up and please share your thoughts with us. Thank you very much. I'm honored to be here today and my topic. Let's go back here. Talk about attention deficit hyperactivity disorder, particularly managing difficult cases with both physicians and therapists really struggle with. The prevalence of ADHD has been much debated over the years. This is the results of a recent study by the Center for Disease Control. Now in this study they did telephone interview with parents. They were not able to directly look at medical records but they would ask. This first slide shows asking parents, has your child ever been diagnosed with ADHD? And this is the percent of people who say yes. And you'll notice that the percentage varies widely across the states from a low of 4% in Utah to highs of nearly 13% in Louisiana. In fact there's that curious sort of duck dynasty belt that runs kind of between Louisiana, Kentucky, over to Virginia where the prevalence appears to be higher than in other states. And we really have no idea what this variation is related to. But if you average this all together you generally get a figure of around 8 to 10% where the parent has said yes the health professional has told me that my child has ADHD. Now that's different from the issue of how many kids then are on medication. So this is asking the parents, has your child ever been placed on a medication for ADHD? Even for just a couple days. And again you see the numbers vary tremendously but typically between roughly about on average about 8% of kids have been treated with medication at some point in their life. It's a little harder to get figures in terms of how many are on medication at any given time. We think probably around 5%. But both these numbers have increased substantially over the last 20 years. And so we struggle both with accurate diagnosis and with the process of providing appropriate treatment. Now I'm not going to go into detail about every one of the stimulant medications that are available for ADHD. There's of course now a wide variety. The methylphenidate products are all broken down into these that you see on the list. They vary not in how effective they are but largely in the mechanism by which the medicine is released into the body and how long acting they are. So concerta, focal an XR, riddle an LA or detrana can generally be given once a day. Whereas the short acting medications obviously have to be dosed multiple times. So these are the methylphenidate products and then the amphetamine class are Adderall, Adderall XR probably best well known and Vivance is a more recent addition. So while Adderall is basically the left and right-handed molecules of amphetamine mixed together and hence gets called its generic name is mixed salts amphetamine the Vivance is simply the right-handed molecule of amphetamine linked to the amino acid lysine so that it has a much longer half-life in the body and thus a longer effective time. So the physician is free to choose whichever one of these he or she wishes in a given case. The bottom line though is as you try one it doesn't work you should kind of move on to another one particularly if a methylphenidate hasn't worked you want to do an amphetamine and vice versa. Now if you'll bear with me here I'm going to kind of do a little pharmacology because there's a curious factor about the stimulant medications which makes them what did I do sorry it makes them different from all of the other commonly used medications. So in this graph here we see the blood level of say methylphenidate given in the morning it rises very quickly and then it wears off so the short acting methylphenidate will last about four hours. Now if you measure the child's behavior when they take the medicine the medicine kicks in and the behavior improves and then by about 11 o'clock the behavior begins to deteriorate. You will notice that the blood level here and you know here and here are roughly the same but the behaviors are dramatically different. So as a result the medicine is most effective when it is entering the brain not so much when it is leaving the brain. And you could see that a little bit better here people often ask exactly what are these medicines doing in the brain. Well here is the it says the methylphenidate effect on DA that stands for dopamine so that is the very light circles here and this is methylphenidate in the brain and methylphenidate in the blood. So the methylphenidate enters the brain very easily and as it does so it increases the amount of dopamine in the brain and it's on this increasing arm that the medicine is most effective. And just very briefly an important point here is that what the methylphenidate is doing once it gets in the brain is it's blocking these dopamine transporters increasing the amount of dopamine in the space between the neurons. That causes the dopamine to stimulate this very complex series of enzymes that are in the the neuron here and once it does that it seems that those effects are present for several hours and it then doesn't matter how much methylphenidate is hanging around in the the the brain once the methylphenidate has thrown the switch. So four hours later you need another dose to throw the switch again and basically the long-acting medicines are ways to hold medicine in reserve so that four hours or eight hours later you kind of whack the neuron again so to speak. Now the there's much written in the literature about the side effects of stimulants if in this graph the green bar is the report of the symptoms at baseline before any medicine has started the yellow is the the amphetamine product and the blue is the methylphenidate and the little marks here the asterisks and whatnot tell you when you know when the rate of the side effect is significantly significant statistically significant over the baseline. So you'll notice the most common side effects of stimulants or trouble sleeping poor appetite. Now notice here is that a lot of ADHD kids are irritable at baseline but in fact in general their irritability gets better when they're on medication and strangely that's true on average for anxiety daydreaming biting fingernails and so on. If we look at things like sadness and and ticks side effects that people are often very concerned about or you hear about in in the media in reality for the group of ADHD kids as a whole these things actually get better when the kids are on medications. Now individual children will have adverse events of mood problems you know feeling slowed down so-called zombie effect but that is in fact quite rare and it goes away of course when the medication is stopped. Now the one long-term side effects of stimulants that we do have some concern about is that they do appear to have some modest effect of growth. It's not clear how many kids this occurs in if you average a whole group of kids together it probably comes out to about two centimeters over the course of three years ending up that it doesn't become progressive. So in many cases this degree of growth suppression is almost not detectable you'd have to measure it very closely with a scale and plot it on a scale it's not something you look at a person say oh he's really short he must have been on a stimulant medication. It's also not associated with any deficit in bone structure or muscles so while it's something to be watched for it is generally not something that is going to cause long-term functional impairment. And then finally ticks it makes surprise you that when they've actually as I say when you actually look at studies you don't find methylphenidate in general or stimulants in general produce more ticks than placebo. Ken Gadow back in 1999 did a lengthy study looking at kids who actually had both tick disorder and ADHD treated them with stimulants and really found they did particularly well on them. So again we watch for ticks when we start the medication but it is not a general side effect not one that generally is going to cause serious problems and of course you would stop the medication if it occurred in in a particular individual. Now about five years ago there was a big hullabaloo about whether stimulants were associated with cardiac problems and there was a brief period of time in which there was concern that every kid with ADHD should have an EKG prior to starting stimulant medication. So Shelman and her colleagues looked at a huge group of kids 240,000 they did this by looking at electronic medical records and compared them to about a million children who did not have ADHD and obviously had never been on ADHD meds. And they looked through these medical records at every type of cardiovascular effect they could imagine sudden death, arrhythmia, stroke, etc. And they found absolutely no relationship between being treated with ADHD and any type of of cardiac side effect. So routine EKGs or routine cardiac monitoring is is not required for treating ADHD. So you have this wide array of stimulants your first decision is choose a methylphenidate choose an amphetamine then once you do that you select the particular product within that class. One very practical question is can the child swallow or not? The long acting forms some of them need to be swallowed whole or if the child can't swallow it then you've got to pop the capsule open and put the stuff in something so they can swallow it that can be a bit messy. So very young children sometimes are started on more of the short acting products. When you try any given stimulant you're generally going to get about a 60 percent response rate that is people come back and say my child's much better his grades have improved he's behaving better and he's not having any significant side effects and that's great. So that stimulant doesn't work usually if it's a methylphenidate then you try an amphetamine or vice versa. And in that case you'll get another 20 percent and people come back and say this is great this works just fine. And then you have this 20 percent of people who are either non-responders or they're very weak responders. Maybe the medicine helped but it only made about a 10 15 percent improvement and there's obviously that's not going to be sufficient. And there's a huge variation in how kids respond and no clinical predictors no way that we can say in advance which medication is better. So I'm often asked by physicians well which one do you always start first? Well I don't have one that I particularly always start first. If the family has heard good things about a particular thing or they have a nephew who did well on it they feel more comfortable with it then that's a perfectly good reason to start that that particular medicine. People say I don't want Ritalin well Ritalin's okay but you really don't like the name Ritalin we can do something else. So there's a little bit of art in all of this as as well as as data. But you the key thing is that to once you start the medicine you want to titrate or increase the dose appropriately. And in your flash drives and if you're with the CME you have this laminated chart with you and the the table that I'm showing here is there which talks about how to dose the stimulants. So typically if we talk about typically a child first grade to third grade you're generally starting if you use concerta as a kind of fence post 18 milligrams a day would be a starting dose. As you go across the rows you see essentially the equivalent starting dose for all the other products. For a young child we're going to go to a maximum dose of concerta of 36 or maximum dose of vivants depending on what you're ever using. As with an adolescent an older adolescent someone 100 pounds and up you can start at a higher dose and go to 72 milligrams or these various equivalent doses along here. If you're treating adult ADHD or you're dealing with an older adolescent who's already adult size you know he's 170 pounds and he's 6'2". Then you can go to the adult doses which are as high as 108 of concerta 90 of methyl phenidate or 40 to 140 of Adderall or 100 of vivants. Now it usually only takes one to two weeks to kind of know whether a given dose of a stimulant is effective. You can talk with people on the phone it's not sufficient you can raise the dose certainly a month is more than enough time. Perhaps the most common mistake that I see made in the treatment of ADHD is physicians begin the starting dose the patient comes back a month later they say there's no improvements they say well let's stop that and they move on to something else or they send them to me and say well he's a stimulant non-responder so I want you to weigh in and then I say to the parents well how high did the dose go well we started 18 and it didn't work so we stopped it and then I usually say well given your child size let's try again at a little bit higher dose. So when I'm talking with parents about the side effects I first I list all the common side effects the loss of appetite the headaches the insomnia the rare side effects that that are not likely to happen but the parents should be on the lookout for and these would be ticks and in include in ticks I would include the biting of fingernails. Some kids very rarely will get this sedation or perseverative effect where they seem side of slowed down this is the so called zombie effect in the lay media it is inappropriately sometimes reported that this zombie effect is somehow the goal of treatment that we're giving the medication to slow kids down or keep them out of trouble by sedating them and that's obviously not true if this effect occurs the the natural response is to just stop the medicine. The long one long-term side effect is talk about the growth reduction as I say is probably very is very minor and then there anyone can have an idiosyncratic reaction to any medication people can take penicillin and have a serious allergic reaction there's nothing like a penicillin reaction there are some you know in some ways stimulants are safer than penicillin because nobody had there's no reports of any massive allergic reaction the way there is to many antibiotics but extremely rarely people can have hallucinations they can become very agitated and activated usually when there's some other psychiatric disorder present in addition to the ADHD. So I always tell people if your child has any unusual change in personality any unusual effect you just stop the medication right away. Given that stimulants are always out of the body every night there is no withdrawal effect in the sense that you have to taper down on the medication gradually if there's a problem you can just stop it right away. Now if the stimulants are not working there are other alternative medications that we can look at probably one of the best well known is atomoxetine or stratera. Now earlier I spoke when I was talking about showed you those pictures of the neurons I showed you dopamine neurons stimulants also in addition to blocking the reuptake of dopamine or increasing the amount of dopamine they also increase the amount of norepinephrine much in the same way the stratera is doing here so there's the stratera. What makes stratera different is that it only blocks the reuptake of norepinephrine and so if there's more norepinephrine in the cleft there's then more communication with this neuron going forward. Now unlike the stimulants which are given every day and then are out of the body atomoxetine is more like other medications it needs to be maintained at a relatively steady state in the bloodstream and so it is given every day you have to reach the therapeutic dose and stay at it for a couple of weeks before you see the full effect. Now stratera or atomoxetine unlike the stimulants it's not a controlled substance so it's very convenient to use it can be called into the pharmacy etc so why isn't stratera just used more widely than the stimulants? Well unfortunately on average stratera is not quite as effective as the stimulants so this study was done where concerto which came is long-acting methylphenidate the stratera and placebo were controlled were compared for six weeks and the stratera was more effective than the placebo but not as effective as the concerta so generally we view the atomoxetine as a second line agent so typically if a child has already been on several stimulants then we'll say well then let's go ahead and do the trial of the stratera and as far as the side effects of side effects of the stratera the common ones are stomach upset sedation in the package insert there's discussion of suicidal ideation you can see the numbers here 0.37 percent versus zero on placebo the this is obviously something you need to discuss with families or warn them about it but in fact it's not clinically important by that i mean all the times i've used stratera have not run into this this particular side effect but given that it did show up in the the studies it is something we always make families aware of and of course we tell them to stop the medication if anything of this sort would occur so when you dose the atomoxetine you start with 0.5 milligram per kilogram per day and you go up to 1.2 milligrams per kilogram per day so typically if you had a eight-year-old boy you'd start with 18 and then you can increase to as much as 20 most of the time we are dividing this you know twice a day usually stratera is taken in the morning and then again in the evening someone's already on a stimulant and they're not doing that great we will stop the stimulant introduce the atomoxetine and in some cases an atomoxetine combined with the stimulant we'll have time i'll talk more about that later now the final class of medications for ADHD are the what we call the alpha agonist the reason we call them the alpha agonist is there are alpha receptors these are the green little triangles here that are both on the neuron that releases the norepinephrine as well as the neuron that accepts the norepinephrine and the alpha agonist whether it's clonidine or guanfacine mimics the action of the norepinephrine so if they clamp on to this receptor they actually decrease the amount of norepinephrine that release it is released if they clamp on to the postsynaptic receptor then they're actually mimicking the effect of the norepinephrine so you've got this curious effect with norepinephrine that could be either increasing it or decreasing it or maybe both at the same time now the traditionally for many years we just had generic guanfacine which also went by the trade name tenix and it would its blood level would rise very high and then drop down then shire developed guanfacine xr or intuniv where they spread the dose out a little bit and it doesn't peak as as much and that intuniv was the product that they then did studies for in order to get the approval for the fda for the product and basically this is a study five-week study the black line or the kids on placebo and you can see that all the different doses of the gxr or the intuniv were superior to the placebo and hence hence the the medication is available to use now the guanfacine or the clonidine are both very different medicines from the stimulants whereas the stimulants have side effects of loss of appetite headaches trouble sleeping the principal side effect of the guanfacine is sleepiness or fatigue but actually as you will see we can potentially use this side effect to our advantage and clonidine xr which is cap va also is better relative to placebo cap va though is more sedative and more likely to lower blood pressure than the guanfacine so that that's something always for physicians to keep in mind now one of the interesting things about the alpha agonist is that they can be combined with the stimulant medications so in this study they took the adhd kids who were already on stimulants and the stimulant was not totally effective so the parents said he's better than nothing but there are still a lot of problems and they used a baseline adhd rating scale that where runs from zero to 54 so if the average is in the high 30s you can tell that they're still on the upper end of the range and these are all the different stimulant medications they are on this is the generic name for Adderall the generic name for concerta and the generic name for vibrance so a good mixture of different stimulants so what they then did is they either added placebo that's the gray bar or they added the guanfacine xr the intuitive and they added it either in the morning or the evening and this is the number of good responders so you can see that uh if when the kids when the medication was the the intuitive was combined with the stimulants you had more positive responders when than just giving placebo so this kind of justifies what was kind of already a long-standing practice which is to combine this alpha agonist medicine with the stimulant when you've got kids who are not fully responding to the stimulant and you can do the same thing with uh clonk with the capvet the clonidine xr so in this graph down is good so this is placebo plus methylphenidate and placebo plus amphetamine uh when you add the methyl when you add the clonidine xr or or either the methylphenidate or the amphetamine you see the bar goes down further although the effect wasn't quite statistically significant the direction of the effect was the same so uh when you again this chart is in that handout when you're uh dosing the capvet or the intuitive it's kind of interesting coincidence that the capvet or the intuitive dose is exactly 10 times that of the capvet so that kind of makes it easy to remember so uh you don't you change the dose every two weeks so with intuitive it's one two three and then with capvet it's point one uh then in the in the evening then the the point two but it split bid and then up to point three and then in older people you can bigger people you can go as high as four milligrams of intuitive or point for a day of capvet but divided be twice a day bid is twice a day uh qhs is at bedtime and then if you're using the old-fashioned uh shouldn't say old-fashioned that sounds pejorative if you're using the short acting generic and inexpensive medication then uh in the dosing is the same it's just that you're dividing it up through the day so for guanfacine that is generally divided twice a day bid or three times a day tid and same thing with the clonidine so we can also use the alpha agonist when a child with adhd has tics either he already has tics at baseline he has a tic disorder or he develops a tic as a part of the as a result of the stimulant treatment so a typical situation as you start stimulant a behavior improves but the tics emerge so you can try to decrease the dose if that doesn't work you switch to a different stimulant you can try the non-stimulant medicine you know strutera by itself or cap vae or intunib by itself but the parents may come back and say well these don't cause the tics but they're not really helping the adhd in which case you would put them back on the stimulant medicine that produced the fewest number of tics and then you could add the alpha agonist uh either the intunib or the cap vae to the stimulant and hope to get the best of both worlds that you are improving the adhd and then the alpha agonist prevents the tics so your overall pharmacological algorithm the one you want to keep in your mind is you always start with a single single stimulant dose it according to the chart make sure you get to the maximum dose assuming side effects don't get in the way and change from one stimulant class to the other then if that doesn't work you can look at a trial of either strutera cap vae or intunib as monotherapy that is using those drugs to treat them by themselves uh I would particularly do that if there was no zero clinical response to the stimulants or severe side effects to the stimulants on the other hand you may have these kids where they're a little bit better on the stimulant you've you've gotten to the max dose and they're 30 percent improved but they're still having problems at school they are still um acting out at home then in that case that's the ideal situation to combine the stimulant and uh the alpha agonist together and with the intunib you can I you usually started in the morning uh along with the stimulant dose on the other hand the study shows you're you can just as easily do it in the evening and since the intunib or all the alpha agonists have sedation as one of their side effects if you have a youngster who the stimulant is causing insomnia by giving the intunib in the evening you may able to you're able to uh deal with that insomnia and thus kind of take care of the whole situation now when the first phase of dealing with ADHD is often very straightforward or even very gratifying everybody sees the immediate response to the medication people are quite grateful but then you have to hunker down for the long term because typically ADHD symptoms don't begin to resolve spontaneously until at least late adolescence and for at least a third of people with ADHD it doesn't resolve in childhood they continue to have problems as adults and the treatment of adult ADHD is now well accepted and there are a number of problems that come to the clinician that need to be dealt with the first is the so-called rebound that is when the medicine wears off at the end of the day there is a period where the child is more active or more agitated or more irritable so you get a situation where things are great at school but the teacher is very happy and the grades have improved but when they get home at night they're actually more difficult than they were to begin with the other is dealing with co-morbidity or co-current concurrent problems the ones i'm going to focus on today are oppositional defiant disorder aggression and mood lability or mood dysregulation and particularly in this latter one you're talking about when is it just mood dysregulation versus when you're getting into the area of bipolar disorder and depression and then i'll talk about what i sort of half jokingly call psychodynamic psychopharmacology that is the process of managing the office visit in such a way that both parent and child you know feel comfortable about what's going on and feel kind of empowered to deal with the problems now rebound as again medication wears off and the behaviors not only return to baseline but they're worse so a key question to ask the parent are you really sure this evening behavior is it just that it's the ADHD behaviors you haven't dealt with or have just returned to the way they always have been and you're seeing the contrast between on medicine off the medicine or is it indeed worse um is the is the uh irritability worse actually when the medicines are fully on board uh or is it only when the meds wear off this is a key question because if the behavior is better during the day and the behavior is worse only in the evening then that's rebound on the other hand if the irritability is worse at the peak time of the stimulant in the middle of the day that's a side effect of the stimulant the stimulant is inducing a negative mood and in generally in that case you're going to want to stop that stimulant and kind of move on to a different approach when you're just dealing with rebound in the evening then you're probably going to keep the stimulant during the day because that's doing pretty well and then you got to look at some options for treating the rebound so if the rebound occurs at 4 p.m uh then of course uh the uh you one option would be to increase the a.m. dose of the long acting stimulant because maybe it's long acting but not quite enough it's it's supposed to last till five or six o'clock but it's going off at 230 so you start at 18 of concerta or 30 of vivance or focal in xr5 and school is better but it's worse right after school well you have room to go up on that a.m. dose go ahead and maximize the a.m. dose according to the chart now uh particularly true if there's a little bit of room for improvement in daytime things aren't perfect yet on the other hand let's say everything is perfect at school can't possibly improve it everything's exactly where it should be but now we're dealing with um the uh the rebound after school then you want to add a short a short acting dose of whatever product they are on in the morning so if they're on a methylphenidate in the morning obviously add a methylphenidate in the afternoon if they're on an amphetamine in the morning add an amphetamine in the afternoon now if this rebound is occurring very late in the evening you know you know the kid it's seven o'clock eight o'clock at night around the time the kid is getting ready to go to bed then obviously you're not going to want to add a stimulant that late that might be if it's mainly sleep problem the rebound is mainly causing sleep problems then you want to add a single short acting dose of an alpha agonist usually the short acting clonidine because it's very sedative and you want the kid to go to bed if the rebound is kind of four or five o'clock it's just throughout the night and it has a lot of irritability associated with it then rather than adding the stimulant you might consider adding the long acting alpha agonist the cap vare the intuniv in that particular situation so the distinction is you know ADHD symptoms are just a rebounding but it's all he's hyper and he's bouncing off the walls but his mood is fine go with the short acting stimulant if it's yes he's hyper and he's bouncing off the walls but he's also cranky and he's crying and he's having meltdowns then you might go with the alpha agonist finally just to reiterate if he's irritable all the time through the day that's a negative mood state and you don't want then you want to change the stimulant so a lot for primary care doctors a lot of problems can be dealt with if you properly deal with rebound and generally you should not be rebounded as a reason for psychiatric referral if the kid's mood is fine in the day the teacher says he's great and it's just this two three hours when it wears off that it's a problem he doesn't take the medicine on the weekend and everything's fine well obviously the kid's not doesn't have a depressive disorder that only lasts between five and eight o'clock at night they so say so you don't want to tie up your referral line with this type of case now once you work through all this rebound and it continues to be a problem then that's a different matter so here's various ways to sculpt the doses in terms of daytime doses afternoon dose i'm not going to go and read these off to you you can obviously look at them yourselves so again add that alpha agonist for the hyper arousal the partial response the sleep issues and the ticks as we've already discussed um so again here is a little more fine-tuned recommendations sleep problems only you want to look at the clonidine don't get into massive doses of clonidine at bedtime so you're given point one that worked okay what the parent says there's a problem still go point two but don't go over point two there are sometimes parents that just get obsessed with having their parents go to their kids go to sleep they're giving extra clonidine and that over point two that can be potentially dangerous so i really really hold the line on that irritability in the evening only you can use the one for seeing ir on the other hand for the all-day irritability or the partial response you can then add the the the intuitive right now let's talk about the sort of some behavior management principles that are unique to adhd and here it is critical to understand of the psychology of the adhd in the first point with adhd there is no why all right what they come in why is he doing this why is he doing this we've explained it to him a hundred times doesn't understand how this makes me feel why is he doing it there is no why the frontal lobe exists for the sole purpose of stopping you from doing stupid things all right and it has evolved over 200 000 years to do that for whatever reason in adhd the frontal lobe doesn't do that and it's not that's unfortunate you know there's no there's no point in asking why it's just a pointless discussion you just you know that your child has or this child has problems with impulse control they always think in short term so the teacher says study your spelling words we are going to have a test tomorrow and the kid says i don't want to study my spelling tests i want to play my video game so they go home and say do you have a spelling test tomorrow no i don't and they play their video games in their mind they are ahead of the game because at that moment they are not studying boring spelling words they are playing their video game and so when they go and they get an f oh crap i got an f uh i'm going to get grounded so i'm not going to take this paper home and get it signed the way i was supposed to because i don't want to get grounded and on and on it goes and it so you it's only by being aware of that in advance and and building the environment around the child to account for that that you're going to make progress just as if you know if if a child is in a wheelchair you're going to put a ramp to get them up into the house or get them where they need to go you're not going to sit around going well why can't they walk why can't they walk you don't build the damn ramp and get them up there so you have to do the same thing i got to communicate with the teacher every day to know what it is that we are going to do and for any teachers in the audience it's the same rule if the parent is cooperative and i realize that sometimes is not always the case but if they are cooperative don't get annoyed if the parent or feel the parent is being a helicopter parent if they are emailing you know what does johnny have do today that's a good thing for the adhd child now naturally parental adhd traits are themselves a problem the parent has adhd or is impulsive and disorganized that's a big deal because adhd kids need more organization more structure than the average child so obviously if you're a parent you recognize the adhd symptoms in yourself certainly try to get them uh they're treated there's just i haven't reviewed it yet but there's just a study come out in cns drugs this month about treating adults with adhd who are parents and observing the effects of the medication on their parenting behaviors and in general their parenting behaviors improve now adhd children do not process rewards and punishments in the same way that typically developing children do they always go for the immediate reward they cannot delay gratification this has been shown in the laboratory over and over again give johnny do you want to have a quarter now or we'll send a dollar to your house in three weeks the typically developing kids said give me the dollar the adhd kid says don't give me the quarter uh and that that that infuses every part of their life i'm going to class my friends are here talking i'm going to sit here and talk with my friends because that's the immediate reward more um interesting is that social rewards are not in the words of behavior management scientists they are not salient i.e. they are not as rewarding and reinforcing so for your at typically developing child you made straight a's that's great i'm so proud of you you know that just is really wonderful um for adhd kids you know not so much you know i have a kid yesterday in the office i said how you're great it's either okay because when i said oh well he made straight a's and he said oh yeah okay because that symbolic awareness is just doesn't it just doesn't give you those that as much uh of a pizzazz as a concrete reward now playing xbox now that's a reward six bucks to go buy something at the store that's a reward so all of the rewards and the consequences need to be very concrete that doesn't mean you certainly continue to include the social praise or the critique when it's necessary but you cannot depend on that alone now this is psychology 101 uh the um and and yet it has to be done and it can't be talked about enough and therapists in the room let me tell you a few things that chat my butt as a psychiatrist you take my patients and you do play therapy with them stop doing that and i get so upset when i talk to my patients how you are here you see dr x or i hear you see mrs g what you do well we talk about my day and we play and you do anything else no now of course the kid maybe he's a kid he remember that was last week but i it is extraordinary how many people continue to do kind of open-ended therapy with adhd kids when the bulk of the time needs to be spent with the parent now granted parents same thing they want to drop they want to drop the kid off at the therapist office let the therapist dip them in the magic therapy and that they're somehow going to change we've been going therapy for three months nothing's changed what has he been doing well he's playing checkers well that's not going to do it you got to sit down with the therapist yourself and talk about some of the things that are going on well you know and i have families i have to educate my style when i do medication management is i really focus on i ask a lot of questions about symptoms and how they're doing because my goal is to optimize the medications and i get parents who want to tell me stories well usually hear what he did last week you know he hit his sister and and i told him not to and he called me the b-word and they're going on and on and on when the details of that story as painful as that is for them are not going to help me adjust the medication what that parent needs to do is go to the therapist and not spend 45 minutes reiterating the story with the therapist but working actively with the therapist okay let's break that incident down and see how we're going to do it differently so i give people this chart and these are just typical goals i usually always have do things first time ask because that kind of covers the water front of oppositional behavior and then i put usually two goals that are individualized for the for the patient and zero is bad one is pretty good and two obviously is excellent and when i tell parents to do is in the afternoon you give the child a rating and you total the points at the bottom for the day if there are any zeros for the day if they get at least one zero then there's a restriction for that evening can't watch tv can't play video games or whatever if you make at least all ones then you have your evening privilege and you continue that process on i i generally go day by day i generally advise parents to start on a saturday and then come through and and the total for the whole week is done on friday and typically 21 points would be a perfectly average week so usually i say if they're below 18 points then there's a restriction for the weekend if there are more than 30 points or 28 points then you get to do some special activity on saturday and sunday and of course on friday an allowance is paid based on the number of points and it's the consistent payout that's more important than the amount so depending on the family's economic means they can do 10 cents a point 50 cents a point a dollar a point whatever you want to do and then the kid can take that money he can save some of it if he wants or or he can then go to the store and and buy a toy or whatever the case may be older kids adolescents obviously they can go shopping clothes etc the uh they can also the final step here is to kind of make one of those fundraising thermometers and color in the amount of points for the week and when the kid gets to some grand total of points then he can get he or she can get some extra special activity or some extra special toy and what this does i tell parents to say is that in a sense they tell the kid they're starting out with the three twos every afternoon or every day and then in the day if things start to get shaky you can say well you know you're bent into two up to now but it's getting it's getting a problem if you don't pull it together i'm going to whack you down to a one and then if they're at the one you say well you're at a one now don't blow it or you're going to be at a zero it gives you it gives the parents some leverage beyond just nagging and yelling and so on and um the also if therapists in particular can ask people to do this every week and bring them back now granted some parents just can't do it they won't do it or whatever the case may be they're often sometimes there's logistical problems the parents working the evening obviously doesn't work a hundred percent of the time but it certainly works better than just uh sort of doing kind of open ended therapy with with adhd kids and this is something physicians can do as well yeah right now i i i basically took about six minutes to explain this whole thing you can have stacks of these in the office you can write out the instructions and attach them to the back and so when parents is all i'm having trouble managing his behavior you can pull one out of the out of the chart out of the the thing you have there in the office that has all your handouts say well here why don't you try this and uh when people say oh that didn't work we've tried that i i always say well this is the best that science has shown worked and you know you really got to give this a try and even the other thing i say is even when it's not working in the short term it may be working it may work in the long term as far as helping the child and manage their their behavior now let's talk about comorbidity this is in the the uh practice uh that we have uh which is a psychiatric practice so it's much more impaired than say what you would see in a primary care setting you would see out of this large number of kids about 40 had what i call adhd simplex that is adhd and no other disorder large proportion of kids with odd and cd and then around the edge of the odd c a cd circle you see the kids with bp or bipolar disorder intermittent explosive disorder mood disorder nos and depression and anxiety and then at the time i did the study the autism spectrum circle was relatively small i think if i repeated that that circle would probably be expanding by now now we always want in adhd we want to distinguish between depression versus dysphoria so major depressive disorder is going to be weeks of daily most of the day depression ongoing suicidal ideation neuro vegetative signs guilt remorse suicidal acts uh there are things in adhd that simulate that which you could call depression if you really wanted to but probably will not respond to an antidepressant medication so adhd kids have brief periods of irritability or unhappiness they're angry at themselves when they've frustrated or done something that messed their lives off and they may say things like well maybe i'll be better off dead but it's not ongoing suicidal ideation um poor sleep is a feature of major depression but then you gotta always bear in mind that being a night owl is relatively typical of adhd people who are depressed tend to be guilty remorseful always negative on themselves i ran in a lot of adhd kids who tell me they don't use these words but this is essentially what they mean i'm depressed because i can't have fun all the time why are you feeling sad well my parents think i should do my homework i have to get up every morning and go to school you know and i'd rather be doing other fun things and i instead the world requires me to do all these other things that i find incredibly boring people will obviously depressed people have suicidal acts and adhd kids because they're very impulsive in some severe situations the cutting behavior tends to be more an expression of anger or a self-stimulatory activity when they're extremely bored now i'm not minimizing the symptoms in the right column what i'm saying is that these are a cluster of symptoms that may not respond very well to antidepressant medication in fact might be a better focus of therapy and i tend to only use antidepressants more in the full-blown depressive episodes now there is a new diagnosis that i'm sure um dr. deuter mentioned the disruptive mood dysregulation disorder uh these are kids who have chronic irritability punctuated by explosive outbursts and you can read the criteria yourself so now in dsm five bipolar should be kids who have an at least five-day period of definite mania associated with um the grandiosity uh pressured speech flight of ideas sexual acting out etc and they generally return to some kind of uh euthymic or or or less disturbed baseline disruptive mood dysregulation disorders are people who are chronically irritable and then have the aggressive outburst stuck on top and then the irritable for the intermittent explosive disorder kids who just have aggressive outbursts and then return uh to baseline uh so this brings up the big elephant in the room when should the anti-psychotic be used in adhd for aggression and there's no doubt that anti-psychotics are very effective for aggression the problem is they're associated with a lot of serious side effects so this is a big deal not something oh he's being kind of aggressive well here's some here's some ability here's some respect at all you know like you know come back in six months um the uh this study that just came out by uh michael a man and colleagues uh looked at a took uh 168 aggressive adhd kids randomized them to either get stimulant or first uh rent first gave them stimulant and behavior therapy for a running period and then randomized them to either get placebo added or get respiradone added and what they found so this is where the respiradone is started what you can see is a lot of the kids improved dramatically in their aggression just with the stimulant and the behavior therapy when they added the the respiradone the respiradone was clearly better than the placebo so that's important to know this is a scientifically justified approach but you can see this difference is not anywhere as big as this difference so we should always try when we've got an adhd aggressive kid we should always try to get as much bang for the buck as we can from just treating the adhd and doing the behavior therapy i talked about but when our back is against the law against the wall the aggression is life threatening it's dangerous to sell for others then that may be the point at which we need to add to the the antipsychotic medication so again add the antipsychotic when there's a significant physical aggression we have aggression in multiple settings danger to sell for others and the psychotherapy has not been helpful or in some cases it is not available and the reality is sometimes it's made necessary by the failure of of other other systems so you know there's not the residential treatment or the therapeutic foster homes or all the other kinds of things that might be available and we've got to be a little bit careful of a medical model of aggression that kind of just says well aggression is treated with antipsychotics or treated with medication so you know people come in and say well he was aggressive last week so we need to increase the medication i think that if that becomes too much of a cliche i think there are dangers and that's coming from me who are a strong advocate of treating aggressive behavior with medication when appropriate all right we have i believe a little time for questions yes we do all right and if you would stand up when you ask your question and project so every oh there's microphones here there's a microphone here and here so please come to the microphone if you're asking a question that will allow us to have more questions because then i won't have to repeat them hello um reshuffle and i'm a pediatrician um actually my question is um regarding like i don't have a phrase this like regarding like social situations and stuff some families are more chaotic how do you differentiate all the adhd that conducts the um oppositional stuff from just unstructured environment lack of good parenting and how do you know when to medicate versus therapy and especially if you have families that refuse to go and aren't compliant with that kind of therapy yeah i um i work that's a very good question and complex issues uh typically if um one way i look at is kids who are doing relatively well at school and the problems are mainly in the home then i'm more likely to stand on my ground and say i don't think medication is needed in this situation and you must or you should go to therapy if uh the school is out of control the kid is not learning not doing well being aggressive at school then i'm more likely to say well i really wish you would be in therapy uh but um the but the situation's urgent enough that i'm going to go ahead and and treat and um the uh i'm not always in the back of my mind i'm thinking maybe in a better environment the kid would be better and maybe he wouldn't need the medicine but then i'm then i always realize that there isn't any there isn't going to be any other environment that's the home that he's going to be in and even if we get and then the final the the the rubber really needs the row when you look at the results of the medication if they improve dramatically on the medicine you feel a little more comfortable that there is something biological going on there are multiple medications that just aren't working then i think you're on stronger ground to say you know maybe this is not a medication issue it's a psychosocial issue well there's limits to how you can force it it's an analogy let's take an analogy in diabetes type two diabetes you have come on someone come in and they're way overweight and they're not eating right you say well you know you wouldn't need your insulin if you lost weight and ate right uh and uh they say well thank you doc but i like the way i eat and but they're glucose is 300 you know then you'd say well i gotta get your prescribe them the insulin even though in your mind you're saying man i wish that patient would would follow my advice and eat healthy so it's an analogous situation just as our society has by providing processed foods and all these other things that we have an obesity epidemic so to some degree you know we have the the rise in adhd may be partially driven by those things but as a physician you're you're always acting in the interest of the individual child uh now so it's always a subjective judgment there's no there's no gold standard if the day comes that we have a diagnostic test for adhd you know that we can do we'll be on firmer ground to saying your brain is typically developing there's no reason why you can't pay attention versus you clearly do have adhd but i'm afraid that's very far away as the kids age into adulthood what's your decision process for seeing if they can manage without the medications uh the uh the question is as kids age what i usually tell parents is observe them during the periods that they're off the medication and if they are doing if they're attention span organizational abilities have improved dramatically and you don't notice a big as big a difference as you used to that's probably the first sign that they're possibly ready to go off the medication if there's an immediate deterioration when the stimulant medication is stopped then then you know we're not ready to do that the um and so if if people say well i'm ready to take a try i usually say well let's start the medicine the first six weeks of school and then you can stop it and of course if but keep in close touch with the teachers and if there's deterioration then just go ahead and restart the medication i have a question about aggression you talked to him about what you'd like to see done therapeutically with kids who adhd is a primary problem when aggression is a you know a big part of the picture is there anything that you recommend in terms of the therapeutic work and is there anything that you see coming back to you that suggests this is more useful than this the uh of course once the aggression i kind of spoke i spoke today kind of in the framework of the child with adhd and aggression without some of these other comorbidities such as depression and bipolar when the aggression is present you kind of go through that process of determining are there other psychiatric disorders present and if they are naturally you're going to treat those the uh but the great bulk of these kids that have this severe mood dysregulation um it's it it is it tends to all revolve around this you know what is one of my patients i i think uh just said frankly you know people make me mad and so his thinking was the problem is that people are making me mad i wouldn't get mad if people would not do this to me so he's trying to make me understand that somehow you know teachers and peers and all these other people just need to stop doing these things and he would never get mad and then that would lead to a discussion he would describe each incident of injustice that led to him getting mad well the teacher said i didn't do the work and i did do the work and my brother you know used my xbox and he didn't ask me to and as a therapist you can very much get lost in the weeds with all of this and therapists are generally taught to be empathic you know reflect back what the patient is thinking so many therapists find themselves saying well that must have made you feel very angry um hoping that that will open the door to some underlying dynamics when in fact a lot of the aggressive dysregulated kids are just sort of may actually find that a reinforcement of their view that yes the world is making me mad so i you know these kids i always say well maybe that's not exactly what made you mad maybe there's something some other big thing in your life that is making you upset is there something going on in the family is there something that happened to you in the past that's an issue and you know 20 of the time i'll hit pay dirt the kid will bring up something that you know is very significant i say well maybe that's part of your anger and the therapist can deal with that a lot of time i just get this i just get mad and i say you know you need to understand you have to control yourself even when you're mad that's kind of the starting point so i'm very big on control you have to control yourself and i do that even to the point of lying myself with a parent whose parenting skills may not be that great i think one trap you get into you know they say well my mom you know the you know my mom called me a bastard and you know one thing to say well mom you shouldn't be calling your child a bastard uh the rather i'd say well and i don't know if your mom said that or not but if she did said that you must have done something that really made her mad and uh you shift the conversation to you need to be the one that controls your behavior and then i think you're much more likely to you know kind of summon whatever residual self-control is there and build on it stemming off of the question before um what research is there if any um on the child going into adulthood and um either getting off the medicine completely because i work at a placement uh group home for children who are in cps care so at that point when they age out at 18 and they no longer you know whether they no longer stick with the caseworker or what have you um they just completely go off the meds i know that the placements do work with them to um taper down but are there any significant side effects slash withdrawal effects of them completely going off of the medication not only just their behaviors um either increasing or worsening from when they were before what they were before but like kind of more of like the withdrawal is there any kind of since it is stimulants and amphetamines we're talking about yeah the stimulants are not going to be any negative side effects they're out as i was mentioning earlier they're out of the body every night anyway now the mood stabilizers they should be tapered off in reality many patients go off cold turkey and the withdrawal effects generally are those are they may be physically uncomfortable you know upset stomach nausea you know occasionally some ticks or twitching but they're not medically dangerous so you know we don't worry about people having seizures or or having some kind of uh really serious medical reaction the for the adhd itself about a third of kids are pretty much are in remission by the time they're in adulthood a third are clearly clearly not in remission and are very symptomatic and then there's a third that's sort of in between where they have some residual symptoms but whether they experience them as impairing depends on the setting they're in so two guys graduate from high school one drives a pizza truck and the other goes to college the person who goes to college may feel he's continued to be impaired because he has to concentrate a lot more than the other fella so the other fella says oh i'm fine i'm getting along okay without the meds i believe we are at the ending point so maybe i'll take this last question and then we'll uh yes this is uh i'm dr shake uh one of the pediatrician my point was what you just described uh you know a lot of teenagers coming back for refills for you know schoolwork how do you feel about that and treating a four five-year-old typical exhibiting typical behavior of aggression and violence all right we'll take the the question of preschoolers if you know for i'm very comfortable with foreign up and i usually in a preschooler i require some evidence of the behavior outside the home and most of the four-year-olds i get referred to me that's fairly easy because they've been expelled from daycare if you can imagine such a thing so it's that severity of symptoms i'm generally fine with with treating it now the the it is there it's a huge ethical dilemma about a lot of kids with adhd they they want the diagnosis because they want accommodations in college and they only you notice that they're only calling for their refill in november and in may when it's exam week and so i'm obviously uncomfortable with that i tell people well if you're not on the medicine most of the time you're probably ready to be offered for good the biggest problem with college adhd is not people asking for too many refills it's actually that they hardly do it or they get one refill in september and it somehow magically lasts uh you know the entire three months of the semester all right thank you thank you very much