Louis B. Cady, MD – CEO & Founder – Cady Wellness Louis B. Cady, MD – CEO & Founder – Cady Wellness Institute Institute Adjunct Clinical Lecturer – Indiana University

School of Medicine Department of PsychiatryChild, Adolescent, Adult & Forensic Psychiatry –

Evansville, Indiana

New Concepts in the Epidemiology, Diagnosis and Precision Treatment of ADHD in Children, Adolescents, and Adults(Slideshare users: this is an updated cover slide)

Grand Rounds – Saint Mary’s Hospital February 5, 2014

Continuing Medical Education Commercial Disclosure Requirement

for Louis B. Cady, M.D.

I, Louis B. Cady, MD, have the following commercial relationships to disclose:•Speaker honoraria received from:

• Immunolaboratories, Great Plains Diagnostic Labs, LABRIX

•Speaker’s bureaus (active) for:• Forest Pharmaceuticals, Sunovion

•Historical data – speaker’s bureau for Bristol-Myers Squibb, Celltech, Cephalon, Eli Lilly, Glaxo-Smith Kline, Janssen, McNeil, Pfizer-Roerig, Sanofi!~aventis, Sepracor, Shire, McNeil, Takeda, Janssen, Searle, Shire, Takeda, Wyeth-Ayerst

This CME presentation is not being underwritten by any pharmaceutical company, and Dr. Cady is not receiving a fee or

honorarium for presenting it.

www.slideshare.net/lcadymd

This is where to follow along on your tablets and smart

phones, or access the presentation slides later…

Note – the 7 True/False “Q & A” for CME documentation of learning are attached at the end of this presentation with the correct answer indicated.

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“Truth is a constant variable.” – William Mayo, MD. “Dr. Will”

Gonda extension, Mayo Clinic Building 2004. © Louis B. Cady, M.D.

Prevalence: how much, and “why so much”?

Prevalence & diagnosis

(NYT, 12 14 2013)

Increased methylphenidate usage for attention deficit disorder in the 1990’s.

Safer DJ et al. Pediatrics. 1996 Dec; 98(6 Pt 1):1084-8}

• 2.5 X increase in MPH tx between 1990 and 1995– 2.8% (1.5 million) US youths aged 5-18 received this

medication in mid-1995

• “The increase in methylphenidate…appears largely related to– an increased duration of treatment;– More girls, adolescents and inattentive youths on the

medication– And a recent improved public image of medication

treatment.”

Prevalence data of parent report of ADHD “CURRENT Dx” by provider

http://www.cdc.gov/ncbddd/adhd/prevalence.html accessed 01 26 2014

2007 2011

IL 4.8% 7.2%

IN 9.3% 13.0%

KY 10.2% 14.8%

Rates of ADHD diagnosis increased an average of 3% per year from 1997 to 2006 (CDC Vital & Health Statistics)

ADHD Stats at 3-17 years of age.

• 5 million children (9% for this age group)– Boys 12%– Girls 5%

• Children with fair/poor health status 2½ X more likely to have dx. (8% vs 21%)

What does it “look like”?

A section for kinesthetic and visual learners…

ADHD – not concentratingInferior Orbital pre-frontal cortex

Images courtesy of Daniel Amen, MD – Amen Clinics, Inc., Newport Beach, CA

ADHD - concentrating

ADHD – concentrating, on RX

ADD – inattentive, without Rx

ADD – inattentive, on Amph

Images courtesy of Daniel Amen, MD – Amen Clinics, Inc., Newport Beach, CA

Diagnostic criteria

DIAGNOSIS: FOUR FLAVORS OF ADHD

314.00 ADHD Predominantly Inattentive Type*

314.01 ADHD Predominant Hyperactive-Impulsive Type*

314.04 ADHD, Combined Type

314.9 ADHD – Not Otherwise Specified

6 of 9 symptoms required for 314.00 & 314.01

– Symptoms present before age 7 (now 12 in DSM-5) years

– Impairment from symptoms present in 2 or more settings

– Significant social, academic, or occupational impairment

– Exclude other mental disorders

Check off the symptoms which are unusually troublesome for your child (or YOU, if you are an adult patient) which are clearly different from what other children or adults typically experience. PLEASE USE THE BACK SIDE OF THIS FORM TO AMPLIFY ON ANY OF THE "CHECKED" SYMPTOMS WHICH YOU FEEL I SHOULD KNOW MORE ABOUT.

ADHD Diagnostic Symptom Checklist, adapted from DSM-IV, by:Louis B. Cady, M.D. - 611 Harriet Street - Suite 304 - Doctors Plaza

Evansville, IN 47710 www.drcady.com

PATIENT NAME: ___________________________ DATE: __________Medication status: ( ) pre-treatment? ( ) on Rx? ( ) OFF of Rx?

PATIENT STATUS: CHILD

ATTENTION PROBLEMSdisplays failure to give close attention to details; makes careless mistakeshas difficulty with sustained attentiondoesn't listen even when spoken to directlyhas REAL trouble following through on instructions; fails to finish tasksdifficulty organizing tasks/activitiesavoids, dislikes, or reluctant to engage in tasks requiring sustained mental effort (homework, work projects, etc.)loses things necessary for tasks/activitieseasily distracted by extraneous stimuli (sounds or sights in the environment)often forgetful in daily activities

HYPERACTIVITY, "WIGGLESOMENESS" PROBLEMS

fidgets with hands or feet, squirms in seatleaves seat in classroom in which remaining in seat was expected, or can't stay put at workruns about; climbs excessively in inappropriate situationsdifficulty playing or engaging in leisure activities quietlyoften was "on the go" as if "driven by a motor"talks excessively - a "chatterbox"

PROBLEMS BEING IMPULSIVEblurts out answers before questions are completeddifficulty waiting your turninterrupts or intrudes on others (butts into conversations)

For physician use only - RECENT CLINICAL HISTORY:

PARENTS: Please feel in your child's

CURRENT DRUG THERAPY... PLEASE LIST!

____________ _________ ________________________ _________ ________________________ _________ ________________________ _________ ________________________ _________ ________________________ _________ ________________________ _________ ____________

medication size of dose WHEN TAKEN

physician use...

DSM-5 update

• 6 symptoms before age 7

• 6 symptoms for adults

• 6 symptoms before age 12

• 5 (FIVE) symptoms for adults

“The Total Picture” diagnostic pearls [from Steven Grcevich, MD]

• Read comments on report cards!

• Ask siblings: “What’s (s)he like to live with?”

• Ask patient: “When was the last time you got invited to someone else’s house to play?”

• Ask parents: “Is (s)he involved with any activities in the community?”

Different symptom manifestation: children through adults

Continuation of Impairment of ADHD

Hopelessness, frustration, giving upBecomesRepetitive failure

Unwanted pregnancy, STDs, etcBecomes

Impulsivity and carelessness

ASPD, criminal involvement

BecomesODD / CD

Drug dependenceBecomesDrug experimentation

Fatal car wrecks / risk taking

BecomesMultiple injuries

Job failure or under-employment

BecomesSchool failure / under-achievement

Adulthood Childhood

Courtesy of William Dodson, MD – Denver, Colorado

Hyperactivity

—Age—

Impulsivity

Inattention

ADHD: Course of the Disorder

Earlier Initiation of Smoking with ADHD

237 6 to 17-year-old boys

0.6

0.5

0.4

0.3

0.2

0.1

0

Sm

oki

ng

pro

bab

ilit

y

0 2 4 6 8 10 12 14 16 18 20 22 24

P<0.003

ADHD n=128Control n=109

Milberger S, et al. J Am Acad Child Adolesc Psychol. 1997;36:37-44.

4 year follow-up

Biederman, et al. Biol Psychiatry. 1998;44:269-273.

Lif

etim

e ra

te o

f su

bst

ance

ab

use

in

ref

erre

d A

DH

D a

du

lts

0

10

20

30

40

50

60

Increased Lifetime Substance Abuse in Untreated Adults with ADHD

55% Control (n=268)

ADHD (n=239)

27%

P<0.001

Biederman J, et al. Pediatrics. 1999;104:e20-e25.

40

30

20

10

0

% o

f st

ud

y p

op

ula

tio

n

UnmedicatedADHD

MedicatedADHD

Control

32

12 10

P<0.001

Pharmacotherapy Significantly Reduces Substance Abuse in Adults

with ADHD

(N=56)(N=19)(N=137)

3-fold!

Horrigan J, et al. Presented at 47th Annual AACAP Meeting: October 24-29, 2000. New York, NY.

What happens if ADHD isn’t treated?

Driving behavior and results in 27 clinically referred German adults

• N=27, with initial screen– 19 studied – initial testing then either:

• 10- kept medication free• 9 – tx’ed for 6 weeks with MPH

Sobanski E, et al. Driving-related risks and impact of metylphendiate treatment on driving in adtuls with attenion-deficit/hyperactivity disorder (ADHD). J Neural Trasm. 2008; 115(2):347-56.

Driving behavior and results in 27 clinically referred German adults

• Background findings:– All ADHD subjects: drove significantly more kilometers per year– More often registered by traffic authorities– Fined more frequently– Involved in more MVA’s– Self described driving style as “more insecure and hectic” than

controls.

• A high risk group was delineated with:– 3-6 MVA’s per ADHD subject

Sobanski E, et al. Driving-related risks and impact of metylphendiate treatment on driving in adtuls with attenion-deficit/hyperactivity disorder (ADHD). J Neural Trasm. 2008; 115(2):347-56.

Do you want to treat them?

STUDY CONCLUSIONS:

MPH tx improved information processingand sustained visual attention compared to baseline and untreated control groups.

Sobanski E, et al. Driving-related risks and impact of metylphendiate treatment on driving in adtuls with attenion-deficit/hyperactivity disorder (ADHD). J Neural Trasm. 2008; 115(2):347-56.

www.billfoster.com - Reviving American Manufacturing, accessed 1 27 2014www.billfoster.com - Reviving American Manufacturing, accessed 1 27 2014

http://www.scdigest.com/assets/newsViews/08-06-12-2.php accessed 01 27 2014http://www.scdigest.com/assets/newsViews/08-06-12-2.php accessed 01 27 2014

Unemployment, underemployment are contemporary problems…

Psychiatric disorders (lifetime) in adults with ADHD [multiple sources, % is estimated; N.B. – this is WITHOUT TREATMENT GROWING UP]

• Substance use disorders (all) 50%• Anxiety disorders 40%

• Major depression 35%

• Learning disabilities 20%

• Bipolar disorder 10%

• Antisocial disorder 10%

Adult ADHD’ers:• Lower self esteem as

adults• Lower educational

achievements• Greater use of ancillary

educational resources• Greater tobacco and

recreational drug use • A lifelong pattern of

“consistent inconsistency.” Source: David Goodman, MD – Johns Hopkins Adult ADHD

treatment center

105 Adult ADHD Drivers vs. 64 Controls (CC)

• ADHD’ers self reported:– More citations (esp. for SPEEDING),

crashes & license suspensions than CC

• ADHD’ers:– less attentive, made more errors on

visual reaction task– Lower scores on driving rules test.

• Driving difficulties: not related to “ODD”, depression, anxiety, or frequency of substance use.

Barkley RA, et al. J Int. Neuropsychol Soc. 2002 (5):655-762.

Drug, drug... who's got the

drug?

We are not there yet.

Response to Psychostimulants

Best Response(Percent)

AMP MPH Equal response to either stimulant

Meta-analysis of Within-Subject Comparative Trials Evaluating Response to Stimulant Medications

28%28%

16%16%

41%41%

.Arnold et al. J Attention Dis. 2000;3:200.

Betting odds:Amph – 69%

MPH 57%

Benefit-Risk Ratio and Efficacyof Psychostimulants

• Very favorable benefit-risk ratio– rapid, dramatic results– low risk of long-term side effects

• Approximately 70% of patients with ADHD will show a positive response on the first trial of any one stimulant medication

• If two different stimulant medications are tried, the response rate increases to ~90%

Greenhill. Child Adolesc Psychiatr Clin North Am. 1995;4:123; Spencer et al. JAACAP. 1996;35:409;Goldman et al. JAMA. 1998;279:1100.

Amphetamines, methylphenidate, and antidepressants - important differences:Amphetamine - increases release and decreases uptake at the DOPAMINE uptake transporter (Seiden, et al., 1993)–effects release of DA from vesicles.

–also allows dopamine to be released from newly synthesized pools inside the cell.

–also activates 5-HT receptors (Sloviter, et al., 1978)

–L-amphetamine = 50/50 NERI/DRI (Stahl, 2013)Methylphenidate - effects release of DA from vesicles only – inhibits dopamine reuptake, as well.

Antidepressants: inhibit reuptake of NE and DA; do not cause release. [Atomoxetine = “NRI”]

Atomoxetine• Superior to placebo (but slightly

less effective than MPH) in large, double-blind, placebo-controlled trial-Heiligenstein, 2000

• Spencer et al. (JCAP 2001)-open study,30 patients, 75% improved >25%.

SE’s: rhinitis, headache, anorexia, dizziness, nervousness, somnolence

• Michaelson (Pediatrics, 2001) ATX>PLB, best response at 1.2 mg/kg/day

• Kratchovil (JAACAP, 2002) ATX=generic MPH, open-label study, inadequately poweredHeiligenstein et al. Presented at AACAP, October 24-29, 2000Spencer et al. J. Child Adolesc Psychopharmacol 2001: 11(3) 229-238

CH3

O NCH3

H

HCl

CH3

O NCH3

H

HCl

“Strattera* [coupled with fluoxetine or paroxetine] has been great for our admissions.”

-Dr. William Beute, MD

Pine Rest Campus Clinic

Grand Rapids, MI

April 21, 2004

[quoted with permission]

* Brand name used in this slide because this is a direct quote

“2P, or not 2P……that is interaction.”

NB: Cytochrome p450 2D6:-This is where atomoxetine is metabolized-It is inhibited by paroxetine and fluoxetine

“Alpha 2a agents”• Concept of SUSTAINED RELEASE AGENTS –

generic instant release agents not the same• Extended release guanfacine – “1,2,3 or 4 mg at

bedtime”• Extended release clonidine – “0.1 – 0.2mg (ER)

twice daily (a.m. and pm)” • Both are approved for monotherapy or for add-on

therapy.• Stimulants seem more potent; alpha-2 Rx seems

to be better for oppositional/defiant symptoms, either by themselves or in combination therapy.

Cady diagram, 2014 – includes current stimulants

STIMULANTS: Time Course Considerations

~4 hrs

2 Classes: MPH or Amph

MPH

MPH

dexMPH

8 hrsMPH LA

12 hrsOROS-MPH

4-5 hrsD-amp

MPH “CD” MPH Patch (12+)

Amphetamines

7-8 hrs 8-10-12Dex spans

Mixed amph salts

AMP salts XR

Dex-MPH SR Lis-dexamph

SR Liquid MPH-12 hrs

Plasma Concentration Profiles Plasma Concentration Profiles Associated with Different MPH Associated with Different MPH Delivery PatternsDelivery Patterns

MPH TWICE DAILY

Flat – MPH sips

Co

nce

ntr

atio

n (

ng/m

L)

Time (h)

15

6

5

4

3

2

1

00 5 10

Simulated plasma methylphenidate concentrations for 20-mg total daily dose delivered by twice-daily (BID), flat, and ascending dosing regimens.from Swanson J, et al. Clin Pharmacol Ther. 1999;66:295-305.

KEY TAKE HOME POINT! The drug level must ASCEND during the day in order to keep the therapeutic effect STEADY.

MPH Oros

“Mixed salts of amphetamines, "handedness,” and efficacy

Amphetamine mixed salts contains:–d - amphetamine sulfate (aka "Dexedrine")

–d,l - amphetamine sulfate–d,l - amphetamine saccharate–D,l – amphetamine aspartate

Dextro-amphetamine 2x as effective as l-amphetamine

–Smith & Davis, 1977; Janowsky & Davis, 1976

The Arnold studies

Randomized, double-blind, placebo controlled31 children with “MBD” (1976)Rx: 5 mg of d-AMP; 7 mg l-AMP [difference d.t. MW's]

CONCLUSIONS (replicated previous 1972 study of n=11):–Both agents found effective–Typically one agent was more effective than the other for individual children

[Arnold LE, Huestis RD, Smeltzer DJ, et al. Levoamphetamine vs dextroamphetamine in minimal brain dysfunction. Arch Gen Psychiatry 33:292-301, 1976

Arnold LE, et al. Levoamphetamine and dextroamphetamine: Differential effects on aggression and hyperkinesis in children and dogs. Am J Psychiatry 130:165-170, 1973]

Typically one agent was more effective Typically one agent was more effective than the other for individual childrenthan the other for individual children

• d-AMP "appeared non-significantly more d-AMP "appeared non-significantly more effective"effective"• slightly better for "over-anxious" childrenslightly better for "over-anxious" children

• l-isomer - 2/3 of children improvedl-isomer - 2/3 of children improved• seemed to be of more benefit to seemed to be of more benefit to

"unsocialized-aggressive" kids"unsocialized-aggressive" kids• 28% of responders preferred the l-AMP form28% of responders preferred the l-AMP form• ““decreased tendency to blunt affect and decreased tendency to blunt affect and

produce the produce the ‘‘amphetamine lookamphetamine look’’ [sic] [sic]””

Substance Use Disorders: Substance Use Disorders: Drugs of Abuse vs Meds for ADHDDrugs of Abuse vs Meds for ADHD

A “struggle” to get kids to take them

A “struggle” to get kids to stop taking them

Readily available but long-term use is rare

Large and ready market exists

Patients commonly forget to take medication

Users crave the drug

Feel nothing or feel bad in overdose

Used to feel good

Medications for ADHDDrugs of Abuse

Courtesy of William Dodson, MD – Denver, Colorado

Drug Delivery & Dosing adjustments

OROS MPH – the first player

GI liquid absorbed

into osmotic matrix pump

MPH pushed out the laser drilled

hole at end of tablet

Peaks & troughs…

Illustration from Alza promotional literature

OROS MPH – 18 mg

OROS MPH &

Delayed-Release Bead

Mixed amphetamine salts “XR” system

Immediate-Release Bead

Bead Core

Overcoating

Release-DelayingPolymer

Capsule

Overcoating

50% 50%

Drug LayerOvercoating

Drug Layer

Bead Core

Available in 5, 10, 15, 20, 25, and 30 mg dosing forms

Chemical Structure of Lis-dexamfetamineChemical Structure of Lis-dexamfetamine

Lis-dexamfetamine is a prodrug that is therapeutically inactive Lis-dexamfetamine is a prodrug that is therapeutically inactive until it is converted to active until it is converted to active dd-amphetamine in the body-amphetamine in the body

l-lysinel-lysine

H NH N22

OO

OHOH

NHNH 22

++

dd-amphetamine-amphetamine(active)(active)

H NH N22

CHCH33

Lisdexamfetamine Lisdexamfetamine (Prodrug)(Prodrug)

H NH N22

OO

NNHH

NHNH 22

CHCH 33

Site of cleavageSite of cleavage

Rate-limited

Hydrolysis

Charged polymer sustained delivery technology

12 hour sustained release LIQUID MPH Rx

Basic MPH 101• How much to Rx?!

• Old dosing charts show 0.3 – 0.7 mg/kg/dose– But only “1.5 mg/kg/day”….

• But THREE doses of 0.3 – 0.7 mg/kg/dose = 0.9 – 2.1mg/kg/day

• THEREFORE, theoretical maximum should be “2.1 mg/kg/day” (the “Biederman max”)

• But what is that really, in “Hoosier-speak”?

Cady/Desiderato Factor-Label, Down-Home, Good-Ole Boy MPH

Calculation:

2.1mg MPH 1 Kg ONE milligram

X =

Kg 2.2 lbs pound of kid

1mg / lb of kid / day

spread out over 12 hours, OR

About ½ that for amphetamines or dex-MPH

Lys-dexamph, amphetamine salts, dex amph, dex-MPH = ½ the

typical amount of methylphenidate

So how much to dose?

• No correlation between plasma level and therapeutic response:– Big levels in small kids– Small levels in big kids

• All medication titrations should be made by informed, observant clinicians with good solid follow-up and examinations

• Titrations should be based on DYSFUNCTION

M.D. does not stand for “minor deity”• Start lower than you think you probably should. • Push it carefully until you get results

– a “just right” therapeutic effect– absent side effects

• Use the “Biederman max” as a rough rule of thumb to calculate the “ceiling,” NOT TO START!

• If you have to “break through the ceiling” – think carefully, document your rationale, monitor carefully for side effects, HTN, cardiac issues

• Explain both the “Goldilocks” and the “Cinderella” aspects to patients/parents

How to screw it up: a case study

• 1/28/14 – 7 year old child presents for tx• Oct 2013 – dx’ed with ADHD• RX:

– Started on 30 mg lys-dexamph from start • Zombied out for two days

– Dosage reduced to 15 mg. Worked well for 3 weeks. “I like the way my brain is working.”

– Began hearing voices in his head at night.

• Medication stopped• Voices persisted over the next 2 weeks, then d/c

QUOTIENT ® TESTING

Case of the “disorganized daughter”• 7/18/12 – 29 yo MWF presents with classic

hypomania, sleep deprivation and psychosis. – Known history of opioid abuse and dependence.

• Per mother: “severe insomnia, mood swings, periodic fits of rage followed by sadness/crying; difficulty concentrating; flight of ideas, trouble managing daily activities; little impulse control”

• Noted to have elevated symptoms of ADHD on initial rating scales

TREATMENT COURSE• By 8/28/2012, stabilized on:

– Paloperidone 6 mg daily + Benztropine 1 mg three times daily

– Lamotrigine started with plan to cross titrate. – Started on PNV with Fe and DHA due to low iron.

• Further history: used opioids to sleep. • Essentially psychiatrically stable. Euthymic.• Viewed as stable enough to take Quotient

test.

BADNESS

GOODNESS

STATS:

•ATTENTIVE 7.5% (!!!) of the time

•Impulsive 47.5% of the time

•Distracted 32.5% of the time

•Disengaged 12.5% of the time

Patient’s response to the Quotient results:

• “Wow, that’s really bad isn’t it?!”

• Asked if she had had severe problems with attention in school.

• “Well, there’s actually something I’ve never told you…”

More history, more treatment

• “I actually used cocaine [therapeutically] before school( in high school) to concentrate.” – Set the curve in all of her finals in her junior year. – Stopped it in her senior year– Used opioid (Lortabs) throughout college to study and

focus. (“It made me awake and helped me do stuff.”).

• Now concerned about her ability to focus.• Brother, in law school, recently dx’ed with ADD.

On mixed amphetamine salts. Doing much better.

Current status: disorganized daughter• RX:

– Lurasidone – 80 mg HS (bipolar)– Lamotrigine – 50 mg per day (bipolar - &

couldn’t go up)– Vilazodone – 30 mg in the a.m.(for OCD

symptoms) – Lisdexamphetamine – 50 mg capsule in a.m. for

ADHD

• Supplements:– L-tyrosine, PNV with Fe and DHA

• Status – perfect function and focus.

Key take-aways from this case

• Don’t let a substance abuse disorder give you a constricted field of logic.

• Affective disorders and ADHD can coexist.

• Frequently ADHD’ers have used illegal drugs or tried their kid’s stimulant.

• Avoid Puritanical blame/self-righteousness:– Many ADHD’ers (and affective disorder patients)

fall into alcohol, marijuana, and other drugs in an attempt to self-treat

• Treat the primary problem first.

Need for systems approach

At home: Two great “how to do it” books

Therapy Axioms: who needs it, when to do it

• The later a child (or adult) is diagnosed, the more complications (s)he has had, and the more conflict – the higher the likelihood of need for psychotherapy

• The converse applies.

• The higher the level of family dysfunction, the more the need for:– “parent training”– Behavioral therapies, etc.

Inventor of NASDAQ screen– Strong family hx of ADHD– Dx’ed at 48 yoa– Interviewed in Time

Square – “Don’t you feel proud?”

–“Not really – all my life, people were telling me I would never amount to anything.”

Quote & identity used by specific permission of David Goodman, MD

& his patient

from: Olazagasti MAR, et al J Am Child Adolesc Psychiatry 2014, Feb 1. published online 2013 January 5 doi:10.1016/j.aaac.2012.11.012

• Prospective 33 year follow up of 135 white boys with ADHD (w/p CD) in childhood & 136 matched comparators w/o ADHD

• “Development of CD/APD accounted for the relationship between ADHD & risk-taking.”

Note: unstandardized co-efficients

Integrated: how to avoid over-reliance on meds

• Smart prescribing!• School:

– Excellent working relationships with school– Good teaching

• HOME:– Diminish “electronic screens” effect– Good home discipline– Good sleep/wake schedules– Good diet– Adequate exercise

• Parent training: parenting, stress tips

“There are things known and there are things unknown, and in between are the doors.”- Jim Morrison

“Probably the most interesting period of medicine has been that of the last few decades. So rapid has been this advance, as

new knowledge developed, that the truth of each year was necessarily modified by new evidence, making the truth an ever-changing factor.”

- Charles Mayo, MD “Dr. Charlie”

Plummer Building lobby. Photo: © Louis

B. Cady, MD 2004

Contact information:Louis B. Cady, M.D.

www.cadywellness.com

www.tmsrelief.com

Office: 812-429-0772E-mail: lcady@cadywellness.com

4727 Rosebud Lane – Suite FInterstate Office Park

Newburgh, IN 47630 (USA)

Q & A – and answers

• Previous epidemiological data suggested prevalence of ADHD in 3 – 7% of school-aged children. According to more recent CDC data (2009) the prevalence is probably around 9% for this group.

– TRUE

• Actually, the reported dx of ADHD by current providers is much higher in the TriState (Indiana, Illinois, & Kentucky), ranging from approximately 7 – 15%. (per CDC Vital & Health Statistics, 1997-2006)

- TRUE

• SPECT imaging, as well as PET and functional MRI, may be a useful way to look at the living brain and observe functioning.

– TRUE  

Q & A – and answers• Here is a comparison and contrast of DSM-IV (in use until

January 1, 2014, and DSM-5 (FIVE) in current use.) Either ALL of the following statements are true, or ALL of them are false.- There are nine symptoms in each domain – nine for inattentiveness and nine for hyperactivity and impulsivity– In DSM-IV, the previous diagnosis criteria specified that any symptoms used for

diagnosis much be present before the age of 7 (SEVEN)– In DSM-V, the current diagnostic criteria specify that the child (or adult) must

have the requisite number of symptoms before the age of 12 (TWELVE).– The difference between the “cutoff” for diagnosis for ADULTS between DSM-IV

and DSM-5 (FIVE) is that in DSM-IV, for the full diagnosis, you had to have at least 6 symptoms in either domain, and now in DSM-5 (FIVE) you just have to have FIVE symptoms as an adult to qualify.

ALL of these statements TRUE

Q & A – and answers• According to common dosing guidelines and the presented “Cady/Desiderato Good Old

Boy Down-Home Guide to Dosing Stimulants,” the theoretical MAXIMUM of methylphenidate products should be 1 mg of methylphenidate per pound of kid per day, and amphetamines should be half that: e.g., ½ mg per lb of kid per day.

– TRUE

• 30 mg of Lisdexamfetamine (brand name = Vyvanse ®)* = 30 mg of amphetamine equivalents for dosing calculations. [*note – brand name is cited here for this medication because this medication is not in generic circulation at this time, and most practitioners will not recognize the generic name.]

– FALSE (oops – this was not covered this a.m.)• Explanation: 30 mg of Vyvanse = 10 mg amphetamine; 50 mg Vyvanse = 20 mg amphetamine; 70 mg of Vyvanse = 30

mg of amphetamine. This is a common dosing error by well meaning pediatricians – confusing Vvanse and amphetamine doses. Sorry for not presenting this.

• According to presented data and recommendation, the two longest acting and smoothest agents in class are lisdexamfetamine and liquid 12 hour sustained release methylphenidate.

– TRUE

It was a great pleasure to present to you this morning! Hope the “Q & A” was helpful. I will be back on April 2nd to present another CME lecture on the use of TMS (transcranial magnetic stimulation) and depression.