ADHD syndrome

As early as the 1940s it became clear that amphetamine could also produce a calming effect in adults prone to aggression and agitation. Later, this so-called paradoxical effect was also seen in children with hyperkinetic syndrome, the precursor to ADHD. 

One exception is the patient with both ADHD and tic disorders such as Tourette s syndrome. High potency antipsychotics have proved quite effective in treating both vocal and motor tics. 

Attention deficit hyperactivity disorder (ADHD) For the treatment of ADHD in patients 6 years of age and older. Dexmethylphenidate is indicated as an integral part of a total treatment program for ADHD that may include other measures (eg, psychological, educational, social) for patients with this syndrome. Drug treatment may not be indicated for all patients. Stimulants are not intended for use in the patient who exhibits symptoms secondary to environmental factors or other primary psychiatric disorders, including psychosis. 

ACLS advanced cardiac life support ACS acute coronary syndrome, American Cancer S ety, American Ctrilege of Surgeons ADH antidiuretic hormone ADHD attention-deficit hyperactivity disorder ADR adverse drug reaction AE adverse events AF atrial fibrillation AHA American Heart Association Al aluminum... 

There is no place anymore for the amphetamines in our therapeutic armamentarium. The only indications for the other stimulants, modaflnil and methylphenidate, are respectively narcolepsy and the attention deflcit disorders (ADHD) and hyperactivity syndromes in children. Their mechanisms of action include enhanced release of dopamine and norepinephrine, re-uptake inhibition of dopamine and norepinephrine and to some extend monoamine oxidase inhibition. 

Comings, D., Gade, R., Muhleman, D., and Sverd, J. (1995) No association of a tyrosine hydroxylase gene tetranucleotide repeat polymorphism in autism, Tourette syndrome, or ADHD. Biol Psychiatry 37 484 86. 

Carter, A.S., O Donnell, D.A., Schultz, R.T., Scahill, L., Leckman, J.F., and Pauls, D.L. (2000) Social and emotional adjustment in children affected with Gilles de la Tourette syndrome associations with ADHD and family functioning. / Child Psychol Psychiatry 41 215-223. 

TACT Study Group, (2002) Treatment of ADHD in children with Tourette s syndrome (TACT Trial). (2002), in press. 

Children with Tourette s syndrome and ADHD refractory to other ADHD medication (n = 29) were treated openly with an average deprenyl dose of 8 mg/ day (Jankovic, 1993). The vast majority of patients (26/29) reported clinical improvement with no serious adverse outcomes. Mild side effects that did not require discontinuation of the drug were noted in six patients. Two patients had exacerbations of their tics. A later controlled trial of low-dose selegiline (10 mg/day) did not demonstrate statistically significant improvement of ADHD symptoms in children with Tourette s syndrome (Feigin et ah, 1996). 

The most common associated adverse effects include appetite suppression, restlessness, activation, tremor, insomnia, and nausea (Preskorn and Othmer, 1984). Delusions and hallucinations (Golden et ah, 1985) as well as tic exacerbations have been observed in children with ADHD and Tourette s syndrome (Spencer et ah, 1993). 

Clonidine 0.003-0.01 bid or tid Tourette s syndrome ADHD Aggression/self-abuse Severe agitation Withdrawal syndromes Sedation (very frequent) Hypotension (rare) Dry mouth Confusion (with high dose) Depression Rebound hypertension Localized irritation with transdermal preparation... 

Preliminary studies suggest that MAOIs are effective in juvenile and adult ADHD. In a controlled trial of clorygline (MAOI-A) and tranylcypromine sulfate (mixed), Zametkin et al. (1985) reported a significant reduction in ADHD symptoms with minimal adverse effects. Eeigin et al. (1996) conducted a controlled trial of 10 mg of selegiline (which at low doses is a specific MAOI-B) in children with ADHD and Tourette s syndrome. Selegiline was well tolerated and was associated... 

Castellanos, F.X., Giedd, J.N., Elia, J., Marsh, W.L., Ritchie, G.F., Hamburger, S.D., and Rapoport, J.L. (1997) Controlled stimulant treatment of ADHD and comorbid Tourette s syndrome effects of stimulant and dose. / Am Acad Child Adolesc Psychiatry 36 589-96. 

To summarize, comorbidities on which a manic syndrome can be superimposed include ADHD, ODD, conduct or pervasive developmental disorders, Tour-ette s syndrome, or medical conditions such as brain tumors, multiple sclerosis, temporal lobe seizures, human immune-deficiency syndrome (HIV), and endocri-nopathies such as hyperthyroidism and Cushing s syndrome (James and Javaloyes, 2001). Organic affective syndrome, a condition given separate designation in DSM I-IIIR, is now subsumed under mood disorder due to a general medical condition in DSM IV. Substance induced mood disorder has a similar due to. . . designation. 

Spencer, T, Biederman, J., Coffey, B.J., Geller, D., Faraone, S., and Willens, T. (2001) Tourette disorder and ADHD. In Cohen, D.J., Jankovic, J., and Goetz, C., eds. Tourette Syndrome and Associated Disorders (Adv Neurol Vol. 85). Philadelphia Lippincott-Williams Wilkins, pp. 57-77. 

Sudden explosive outbursts have been described in 25% of patients with Tourette s Syndrome (TS) (Bud-man et al., 2000). These explosive TS patients had high rates of ADHD (95%), OCD (92%), and ODD (54%). 

When two or more different treatments are used concomitantly, it may be of interest to study in the same experiment both the effects due to each treatment (main effects) and the possible interaction between them (interaction effect). Interaction here means that the effect of one treatment is modified (e.g., decreased or enhanced) by the coadministration of the other treatment. In these cases, a factorial design can be considered. This design has been used, for instance to study the effects of clomidine and methylphenidate administered separately or in combination to children with ADHD and tic disorders (Tourette s Syndrome Study Group 2002). The simplest form is the 2x2... 

Note Doses are provided as general guidelines only, and are not meant to be definitive. All doses must be individualized and monitored through appropriate clinical and/or laboratory means. ADHD, attention-deficit hyperactivity disorder bid, twice daily c, capsule CYP, cytochrome P450 EKG electrocardiogram FDA, Food and Drug Administration IM, intramuscular MDD, major depressive disorder OCD, obsessive-compulsive disorder PDD, pervasive developmental disorder qd, once daily qhs each bedtime qoWk, every other week t, tablet tid, three times daily TS, Tourette s syndrome WBC, white blood cell count. 

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