• Anixety Disorders (OCD, Separation Anxiety, Social Phobia)
• Attention Deficit and Disruptive Behavior Disorders
• Eating Disorders (AN, BN)
• Elimination Disorders (Enuresis -- repeated voiding of urine into inappropriate places)
• Mood Disorders (Depression, Bipolar)
• Pervasive Developmental Disorders (Autism)
• Schizophrenia
• Tic Disorders (Tourette's Disorder)

Biological Influences

• Injury
• Infection
• Poor nutrition during pregnancy
• Exposure to toxins (lead)
• Prenatals tobacco/EtOH use
• Perinatal trauma
• Traumatic brain injury
• Chromosomal syndroms

Psychological Factors

• Severe parental discord
• Parents psychotherapy/criminality
• Large family size/overcrowding
• Economic hardship
• Exposure to violence
• Poor care giving practices
• Security of parental attachment
• Exposure to inconsistent discipline

Genetics

Parental Depression

Stressful Life Events

Childhood Maltreatment

• physical abuse
• Psychological maltreatment

Peer/Sibling Influences

• Sibling rivalry

MultiModal Therapy

Psychotherapy

• Supportive
• Psychodynamic
• Cognitive-behavioral
• Interpersonal
• Family systems

Psychopharmacology

• Many meds used "off label"
• Monotherapy vs combined treatment

• BZDs for acute symptoms
• SSRIs are considered 1st line for long term
• TCAs are not as effective as SSRIs -- tolerability is poor

Psychotherapy

1st line is alarms

Psychopharmacology

1st line is Desmopressin

2nd line are TCAs

• SSRIs (fluoxetine is best studied) are considered 1st and 2nd line
• TCAs are not effective
• Other antidepressants considered 3rd line

• Moos stabilizers are considered 1st line
• Antipsychotics may be useful if psychotic features are present (abilify, seroquel)

• Antipsychotics may be effective for aggression/perseveration
• Antidepressants controversial for anxiety/obsessive-compulsive symptoms

• Suicide?
• Mania/Restlessness/Agitation
• Insomnia
• Nausea/vomtiing/weight loss or gain

• Sedation
• Anticholinergic
• Arrhythmias
• Unexplained death

Uses

ADHD

CI

Eating Disorder

ADRs

Seizure, insomnia, weight loss

Uses

ADHD, Depression, OCD, Autism

ADRs

Suicide, weight loss, NV

Use

• Bipolar disorder
• Conduct disorder

ADRs

• Tremor/fatigue/ataxia/malaise
• Leukocytosis
• Hypothyroidism/diabetes/hair loss
• Nausea/diarrhea
• Enuresis

Use

Bipolar Disorder

ADRs

• Drowsiness/dizziness/vertigo
• Aplasic anemia
• Nausea

Use

Bipolar Disorder

ADRs

• Sedation/tremor
• Hyperglycemia
• Hepatic insufficiency
• Nausea/Vomiting/Increased appetite/Weight gain

Use

• Autism
• Schizophrenia
• Tourette's Disorder
• Conduct Disorder
• ADHD

ADR

• Sedation
• Tardive dyskinesia

Use

• Autism
• Schizophrenia
• Bipolar Disorder
• Tourette's Disorder
• Conduct Disorder

ADRs

• Sedation
• Extrapyramidal effects
• Hepatic insufficiency
• Weight gain

Use

Schizophrenia

ADRs

• Sedation
• Seizure
• Neutropenia

Use

Bipolar, Schizophrenia

Also may be useful for acute mania, autism

ADRs

• Sedation
• Extrapyramidal effects
• Hepatic insufficiency
• Weight gain

Use

Bipolar, Schizophrenia, Autism

ADRs

• Extrapyramidal effects
• Somnolence
• Tremor

Use

Bipolar, Schizophrenia

ADRs

• EPS
• Somnolence
• Increased BP
• Increase weight

Use

Autism, ADHD, Tourette's Disorder, Aggression

ADRs

Rebound HTN, sedation

1. Inattentiveness
2. Hyperactivity
3. Impulsivity

1.  Combined Type (ADHD/C)

Meets 6/9 behaviors in both inattention and hyperactive-impulsive lists

2.  Predominantly Inattentive Type (ADHD/I)

Meets 6/9 inattention behaviors

3.  Predominantly Hyperactive-Impulse Type (ADHD/HI)

Meets 6/9 hyperactive-impulsive behaviors

• Fails to give close attention to detail
• Difficulty sustaining attention
• Does not seem to listen
• Does not follow through on instructions and fails to finish schoolwork, chores, etc.
• Difficulty organizing tasks and activities
• Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort
• Often loses things necessary for tasks and activities
• Easily distracted
• Forgetful

• Fidgets with hands or feet or squirms in seat
• Restless during activities when others are seated
• Runs about or climbs excessively in inappropriate situations
• Excessively loud
• "On the go" or as if "driven by a motor"
• Talks excessively

• Blurts out answers
• Difficulty awaiting turn
• Interrupts or intrudes
• Acts without thinking
• Impatient
• Uncomfortable doing things slowly and systematically
• Difficult to resist temptations or opportunities

Non-Pharm

1.  Psychosocial Interventions

• Contingency management
• Parent training
• Clinical behavior therapy
• Cognitive-behavioral treatment

2.  Multimodal Management

• Psychosocial combination treatment strategy

Pharmacological Interventions

1. CNS Stimulants
2. Pemoline
3. Antidepressants
4. Atomoxetine
5. Alpha2 Adrenergic Agonists
6. Antipsychotics

• Ritalin 
• Ritalin SR
• Ritalin LA
• Concerta
• Methylin
• Methylin ER
• Metadate ER
• Metadate CD
• Daytrana

• Focalin
• Focalin XR

• Dextroamphetamine
• Adderall
• Adderall XR
• Vyvanse

Onset

Fast (15-30min)

Duration

Short (4-6 hrs)

Ages > 6 yo

Onset

Intermediate (longer than Ritalin)

Duration

Intermediate (8 hrs)

Ages > 6 yo

Onset

Intermediate (longer than Ritalin)

Duration

Intermediate (8 hrs)

Ages > 6 yo

Onset

Intermediate (longer than Ritalin)

Duration

Intermediate (8 hrs)

Ages > 6 yo

Onset

Rapid (Tmax₁ = 1-3 hr, Tmax₂ = 5-7)

Duration

Long (8 hrs)

Ages > 6 yo

Onset

Rapid (Tmax₁ = 1-2 hr, Tmax₂ = 6-8 hr)

Duration

Longest

Ages > 6 yo

Onset

Rapid (Tmax₁ = 1-2 hr, Tmax₂ = 4-5 hr)

Duration

Long

Ages > 6 yo

Onset

Fast (2hrs)

Duration

Long (12 hrs)

Ages > 6 yo

d-enantiomer of MPH (more active)

Onset

Fast

Duration

Short

Ages > 6 yo

Conversion from MPH to Focalin is 1/2 the dose of racemic MPH

d-enantiomer of MPH (more active)

Onset

Fast (Tmax₁ = 1-1.5 hr, Tmax₂ = 6-6.5)

Duration

Long

Ages > 6 yo

Conversion from MPH to Focalin XR is 1/2 the dose of racemic MPH

Onset

Fast (15-30 min)

Duration

Short (2-6 hrs)

Ages > 3 yo

Conversion from MPH to amphetamine is 1/2 the dose of racemic MPH

Onset

Intermediate (45 min)

Duration

Intermediate (6-8 hrs)

Ages > 3 yo

Conversion from MPH to amphetamine is 1/2 the dose of racemic MPH

Onset

Intermediate (45 min)

Duration

Longer acting

Ages > 6 yo

Conversion from MPH to amphetamine is 1/2 the dose of racemic MPH

Prodrug of dextroamphetamine

Onset

Long (3.5 hr)

Duration

Longer acting

Ages > 3 yo

Conversion from MPH to amphetamine is 1/2 the dose of racemic MPH

MOA

DA agonist with minimal sympathomimetic effects

Duration

Long-acting

Place in Therapy

• Rarely used b/c of rare but potentially fatal hepatotoxicity
• Currently not recommended by the AAP as either 1st or 2nd line treatment for ADHD

• Baseline EKG, HR, BP
• Sleep patterns
• Eating patterns
• Height
• Weight

MOA

Selective NE Reuptake Inhibitor

Place in Therapy

• Useful as adjunct to stimulants or ALONE for inattentive-type ADHD
• Less abuse risk

• Liver toxicity (pts must have baseline LFTs)
• Dyspepsia
• N/V
• Fatigue
• Decreased appetite
• Dizziness
• Headache
• Mood swings
• Increased BP/HR
• Constipation
• Dry mouth
• Impotence

MOA

stimulates alpha2 adrenoreceptors

Place in Therapy

Added on as adjunct to therapy for pts with tic disorders

• Dry mouth
• Drowsiness
• Headache
• Anorexia
• Hypotension