Christian Jonathan Haverkampf, M.D.

Transcription

1 Christian, M.D. ADHD has become treatable with the medication and psychotherapeutic approaches that have become available. This article gives an overview of the medication used for ADHD. Keywords: ADHD, attention deficit hyperactivity disorder, medication, psychiatry 2018 Christian. All Rights Reserved. 1

2 Table of Contents Introduction... 4 Baseline assessment... 4 Medication for Children... 5 Medication for Adults... 5 Dose Titration... 6 Coexisting Conditions... 7 Anxiety, Tics, Autism... 7 Acute psychotic or manic episode... 7 Extended Release... 7 Monitoring... 7 Behavior... 7 Height... 8 Weight... 8 Cardiovascular... 8 Tics... 8 Sexual dysfunction... 9 Seizures... 9 Sleep... 9 Compliance... 9 Stimulant diversion... 9 Review of medication and discontinuation... 9 Methylphenidate Effects on the QT interval Contraindications Hypertension and Other Cardiovascular Conditions The Cardiovascular Status Children and Adolescents Adults Psychosis Christian. All Rights Reserved. 2

3 Bipolar Disorder Aggression Long-Term Suppression of Growth Seizures Priapism Peripheral Vasculopathy, Including Raynaud s Phenomenon Visual Disturbance Drug Dependence Drug Interactions Carcinogenesis/Mutagenesis Impairment of Fertility Pregnancy Adverse Reactions Psychotherapy References Christian. All Rights Reserved. 3

4 Introduction Stimulants are frequently used to treat attention deficit-hyperactivity disorder. A stimulant is a drug that stimulates the central nervous system, increasing arousal, attention and endurance. Because the medications can be addictive, patients with a history of drug abuse are typically monitored closely or treated with a non-stimulant. It is argued that the risk of addiction in patients diagnosed with ADHD is much lower. Common stimulants include: Methylphenidate (Methylphenidate, Concerta ), a norepinephrine-dopamine reuptake inhibitor Dextroamphetamine (Dexedrine ), the dextro-enantiomer of amphetamine Dexmethylphenidate (Focalin ), the active dextro-enantiomer of methylphenidate Lisdexamfetamine (Vyvanse ), a prodrug containing the dextro-enantiomer of amphetamine There are also mixed amphetamine salts, such as Adderall, a 3:1 mix of dextro/levo-enantiomers of amphetamine. Atomoxetine (Strattera ) is a norepinephrine (noradrenaline) reuptake inhibitor which is approved for the treatment of attention deficit hyperactivity disorder (ADHD). There are also some antidepressants that have mild stimulant effects. Further information can be found in the author s book An Overview of Psychiatric Medication (Haverkampf, 2018) Baseline assessment Before starting medication for ADHD, people with ADHD should have a full assessment, possibly through their GP, which should include: a review to confirm they continue to meet the criteria for ADHD and need treatment a review of mental health and social circumstances, including: presence of coexisting mental health and neurodevelopmental conditions current educational or employment circumstances risk assessment for substance misuse and drug diversion care needs There should also be a review of physical health, including: a medical history, taking into account conditions that may be contraindications for specific medicines current medication height and weight (measured and recorded against the normal range for age, height and sex) baseline pulse and blood pressure (measured with an appropriately sized cuff and compared with the normal range for age) 2018 Christian. All Rights Reserved. 4

5 a cardiovascular assessment an electrocardiogram (ECG) if the treatment may affect the QT interval. One should refer for a cardiology opinion before starting medication for ADHD if any of the following apply: history of congenital heart disease or previous cardiac surgery history of sudden death in a first-degree relative under 40 years suggesting a cardiac disease shortness of breath on exertion compared with peers fainting on exertion or in response to fright or noise palpitations that are rapid, regular and start and stop suddenly (fleeting occasional bumps are usually ectopic and do not need investigation) chest pain suggesting cardiac origin signs of heart failure a murmur heard on cardiac examination blood pressure that is classified as hypertensive for adults Refer to a pediatric hypertension specialist before starting medication for ADHD if blood pressure is consistently above the 95th centile for age and height for children and young people. Consider offering Medication for Children 1. Methylphenidate as the first line pharmacological treatment, 2. Lisdexamfetamine for those who have had a 6 week trial of methylphenidate at an adequate dose and not derived enough benefit in terms of reduced ADHD symptoms and associated impairment, 3. Dexamfetamine for those whose ADHD symptoms are responding to lisdexamfetamine but who cannot tolerate the longer effect profile, 4. Atomoxetine or Guanfacine if: they cannot tolerate methylphenidate or lisdexamfetamine or their symptoms have not responded to separate 6 week trials of lisdexamfetamine and methylphenidate, having considered alternative preparations and adequate doses. Consider offering Medication for Adults 1. Lisdexamfetamine or Methylphenidate as first-line pharmacological treatment, 2. Lisdexamfetamine for those who have had a 6 week trial of methylphenidate at an adequate dose but have not derived enough benefit in terms of reduced ADHD symptoms and associated impairment, Methylphenidate for those who have had a 6 week trial of lisdexamfetamine at an adequate dose but have not derived enough benefit in terms of reduced ADHD symptoms and associated impairment, 2018 Christian. All Rights Reserved. 5

6 3. Dexamfetamine for those whose ADHD symptoms are responding to lisdexamfetamine but who cannot tolerate the longer effect profile, 4. Atomoxetine if: they cannot tolerate lisdexamfetamine or methylphenidate or their symptoms have not responded to separate 6 week trials of lisdexamfetamine and methylphenidate, having considered alternative preparations and adequate doses. Do not offer any of the following medication for ADHD without advice from a tertiary ADHD service: guanfacine for adults clonidine for children with ADHD and sleep disturbance, rages or tics atypical antipsychotics in addition to stimulants for people with ADHD and coexisting pervasive aggression, rages or irritability other medication than that listed above. Dose Titration During the titration phase, ADHD symptoms, impairment and adverse effects should be recorded at baseline and at each dose change on standard scales by parents and teachers, and progress reviewed regularly (for example, by weekly telephone contact) with a specialist. Titrate the dose against symptoms and adverse effects in line with guidelines until dose optimization is achieved, that is, reduced symptoms, positive behavior change, improvements in education, employment and relationships, with tolerable adverse effects. Ensure that dose titration is slower and monitoring more frequent if any of the following are present in people with ADHD: neurodevelopmental disorders (for example, autism spectrum disorder, tic disorders, learning disability) mental health conditions (for example, anxiety disorders [including obsessive compulsive disorder], schizophrenia or bipolar disorder, depression, personality disorder, eating disorder, post-traumatic stress disorder, substance misuse) physical health conditions (for example, cardiac disease, epilepsy or acquired brain injury). Think about using immediate- and modified-release preparations of stimulants to optimize effect (for example, a modified-release preparation of methylphenidate in the morning and an immediate-release preparation of methylphenidate at another time of the day to extend the duration of effect). Be cautious about prescribing stimulants for ADHD if there is a risk of diversion for cognitive enhancement or appetite suppression. Do not offer immediate-release stimulants or modified-release stimulants that can be easily injected or insufflated if there is a risk of stimulant misuse or diversion Christian. All Rights Reserved. 6

7 Prescribers should be familiar with the requirements of controlled drug legislation governing the prescription and supply of stimulants. See NICE's guideline on controlled drugs. Coexisting Conditions Anxiety, Tics, Autism Offer the same medication choices to people with ADHD and anxiety disorder, tic disorder or autism spectrum disorder as other people with ADHD. Acute psychotic or manic episode Stop any medication for ADHD. Consider restarting or starting new ADHD medication after the episode has resolved, taking into account the individual circumstances, risks and benefits of the ADHD medication. Extended Release When prescribing stimulants for ADHD, think about modified-release once-daily preparations for the following reasons: convenience improving adherence reducing stigma (because there is no need to take medication at school or in the workplace) reducing problems of storing and administering controlled drugs at school the risk of stimulant misuse and diversion with immediate-release preparations their pharmacokinetic profiles. Immediate-release preparations may be suitable if more flexible dosing regimens are needed, or during initial titration to determine correct dosing levels. Monitoring Behavior Monitor the behavioral response to medication, and if behavior worsens adjust medication and review the diagnosis Christian. All Rights Reserved. 7

8 Height Height: measure height every 6 months in children and young people; measure weight every 3 months in children 10 years and under; use a growth chart Weight Weight: measure weight at 3 and 6 months after starting treatment in children over 10 years and young people, and every 6 months thereafter, or more often if concerns arise; measure weight every 6 months in adults If weight loss is a clinical concern, consider the following strategies: taking medication either with or after food, rather than before meals taking additional meals or snacks early in the morning or late in the evening when stimulant effects have worn off obtaining dietary advice consuming high-calorie foods of good nutritional value taking a planned break from treatment changing medication. If a child or young person's height over time is significantly affected by medication (that is, they have not met the height expected for their age), consider a planned break in treatment over school holidays to allow 'catch up' growth. Consider monitoring BMI of adults with ADHD if there has been weight change as a result of their treatment and changing the medication if weight change persists. Cardiovascular Monitor heart rate and blood pressure and compare with the normal range for age before and after each dose change and every 6 months. If a person taking ADHD medication has sustained resting tachycardia (more than 120 beats per minute), arrhythmia or systolic blood pressure greater than the 95th percentile (or a clinically significant increase) measured on 2 occasions, reduce their dose and refer them to a pediatric hypertension specialist or adult physician. If a person taking guanfacine has sustained orthostatic hypotension or fainting episodes, reduce their dose or switch to another ADHD medication. Tics If a person taking stimulants develops tics, think about whether the tics are related to the stimulant (tics naturally wax and wane) and the impairment associated with the tics outweighs the benefits of ADHD treatment. If tics are stimulant related, reduce the stimulant dose, or consider changing to guanfacine (in children aged 5 years and over and young people only), atomoxetine, clonidine, or stopping medication Christian. All Rights Reserved. 8

9 Sexual dysfunction Monitor patients with ADHD for sexual dysfunction, particularly erectile and ejaculatory dysfunction, as potential adverse effects of atomoxetine. Seizures If a person with ADHD develops new seizures or a worsening of existing seizures, review their ADHD medication and stop any medication that might be contributing to the seizures. After investigation, one may cautiously reintroduce the ADHD medication if it is unlikely to be the cause of the seizures. However, this may not be easy to determine. It also depends on any medication the individual may be taking against the seizures. Sleep Monitor changes in sleep pattern (for example, with a sleep diary) and adjust medication accordingly. Compliance Encourage the person with ADHD to use the following strategies to support adherence to treatment: being responsible for their own health, including taking their medication as needed following clear instructions about how to take the medication in picture or written format, which may include information on dose, duration, adverse effects, dosage schedule (the instructions should stay with the medication, for example, a sticker on the side of the packet) using visual reminders to take medication regularly (for example, apps, alarms, clocks, pill dispensers, or notes on calendars or fridges) taking medication as part of their daily routine (for example, before meals or after brushing teeth) peer support groups for patients, their families and carers. Also, try to address any misconceptions. ADHD medication does not alter one s personality when used for its intended purpose. Stimulant diversion It should always be kept in mind that stimulant medication is misused and can be sold by a patient. Review of medication and discontinuation The medication should be reviewed at least twice a year and discussed with the person with ADHD. The need for continued medication needs to be answered each time Christian. All Rights Reserved. 9

10 Consider trial periods of stopping medication or reducing the dose when assessment of the overall balance of benefits and harms suggests this may be appropriate. Methylphenidate Methylphenidate hydrochloride USP is a mild central nervous system (CNS) stimulant, available in immediate or long-acting preparations. It presumably activates the brain stem arousal system and cortex to produce its stimulant effect. The following information may be incomplete and incorrect, even at the time of writing. It is just included to give a rough overview of some of the topics that may be encountered when deliberating medication or discussing it with a client. Methylphenidate is indicated as an integral part of a total treatment program which typically includes other remedial measures (psychological, educational, social) for a stabilizing effect in children with a behavioral syndrome characterized by the following group of developmentally inappropriate symptoms: moderate-tosevere distractibility, short attention span, hyperactivity, emotional lability, and impulsivity. The diagnosis of this syndrome should not be made with finality when these symptoms are only of comparatively recent origin. Non-localizing neurological signs, learning disability, and abnormal EEG may or may not be present, and a diagnosis of central nervous system dysfunction may or may not be warranted. Drug treatment is not indicated for all children with this syndrome. Stimulants are not intended for use in the child who exhibits symptoms secondary to environmental factors and/or primary psychiatric disorders, including psychosis. Appropriate educational placement is essential and psychosocial intervention is generally necessary. When remedial measures alone are insufficient, the decision to prescribe stimulant medication will depend upon the physician s assessment of the chronicity and severity of the child s symptoms. Methylphenidate should not be used in children under 6 years, since safety and efficacy in this age group have not been established. Effects on the QT interval In one study, the maximum mean prolongation of QTcF intervals was <5 ms, and the upper limit of the 90% confidence interval was below 10 ms for all time matched comparisons versus placebo. This was below the threshold of clinical concern and there was no evident-exposure response relationship. Contraindications Marked anxiety, tension, and agitation are contraindications to Methylphenidate, since the drug may aggravate these symptoms. Methylphenidate is contraindicated also in patients known to be hypersensitive to the drug, in patients with glaucoma, and in patients with motor tics or with a family history or diagnosis of Tourette s syndrome. Methylphenidate is contraindicated during treatment with monoamine oxidase inhibitors, and within a minimum of 14 days following discontinuation of a monoamine oxidase inhibitor (hypertensive crises may result) Christian. All Rights Reserved. 10

11 Hypertension and Other Cardiovascular Conditions Stimulant medications cause a modest increase in average blood pressure (about 2-4 mmhg) and average heart rate (about 3-6 bpm), and individuals may have larger increases. While the mean changes alone would not be expected to have short-term consequences, all patients should be monitored for larger changes in heart rate and blood pressure. Caution is indicated in treating patients whose underlying medical conditions might be compromised by increases in blood pressure or heart rate, e.g., those with preexisting hypertension, heart failure, recent myocardial infarction, or ventricular arrhythmia. The Cardiovascular Status Children, adolescents, or adults who are being considered for treatment with stimulant medications should have a careful history (including assessment for a family history of sudden death or ventricular arrhythmia) and physical exam to assess for the presence of cardiac disease and should receive further cardiac evaluation if findings suggest such disease (e.g., electrocardiogram and echocardiogram). Patients who develop symptoms such as exertional chest pain, unexplained syncope, or other symptoms suggestive of cardiac disease during stimulant treatment should undergo a prompt cardiac evaluation. Children and Adolescents Sudden death has been reported in association with CNS stimulant treatment at usual doses in children and adolescents with structural cardiac abnormalities or other serious heart problems. Although some serious heart problems alone carry an increased risk of sudden death, stimulant products generally should not be used in children or adolescents with known serious structural cardiac abnormalities, cardiomyopathy, serious heart rhythm abnormalities, or other serious cardiac problems that may place them at increased vulnerability to the sympathomimetic effects of a stimulant drug. Adults Sudden death, stroke, and myocardial infarction have been reported in adults taking stimulant drugs at usual doses for ADHD. Although the role of stimulants in these adult cases is also unknown, adults have a greater likelihood than children of having serious structural cardiac abnormalities, cardiomyopathy, serious heart rhythm abnormalities, coronary artery disease, or other serious cardiac problems. Adults with such abnormalities should also generally not be treated with stimulant drugs. Psychosis Administration of stimulants may exacerbate symptoms of behavior disturbance and thought disorder in patients with a preexisting psychotic disorder. Bipolar Disorder Particular care should be taken in using stimulants to treat ADHD in patients with comorbid bipolar disorder because of concern for possible induction of a mixed/ manic episode in such patients. Prior to initiating treatment with a stimulant, patients with comorbid depressive symptoms should be adequately screened 2018 Christian. All Rights Reserved. 11

12 to determine if they are at risk for bipolar disorder; such screening should include a detailed psychiatric history, including a family history of suicide, bipolar disorder, and depression. Treatment emergent psychotic or manic symptoms, e. g., hallucinations, delusional thinking, or mania in children and adolescents without a prior history of psychotic illness or mania can be caused by stimulants at usual doses. If such symptoms occur, consideration should be given to a possible causal role of the stimulant, and discontinuation of treatment may be appropriate. In a pooled analysis of multiple shortterm, placebo-controlled studies, such symptoms occurred in about 0.1% (4 patients with events out of 3,482 exposed to methylphenidate or amphetamine for several weeks at usual doses) of stimulant-treated patients compared to 0 in placebo-treated patients. Aggression Aggressive behavior or hostility is often observed in children and adolescents with ADHD and has been reported in clinical trials and the post-marketing experience of some medications indicated for the treatment of ADHD. Although there is no systematic evidence that stimulants cause aggressive behavior or hostility, patients beginning treatment for ADHD should be monitored for the appearance of or worsening of aggressive behavior or hostility. Long-Term Suppression of Growth Careful follow-up of weight and height in children ages 7 to 10 years who were randomized to either methylphenidate or non-medication treatment groups over 14 months, as well as in naturalistic subgroups of newly methylphenidate-treated and non-medication treated children over 36 months (to the ages of 10 to 13 years), suggests that consistently medicated children (i.e., treatment for 7 days per week throughout the year) have a temporary slowing in growth rate (on average, a total of about 2 cm less growth in height and 2.7 kg less growth in weight over 3 years), without evidence of growth rebound during this period of development. Published data are inadequate to determine whether chronic use of amphetamines may cause a similar suppression of growth, however, it is anticipated that they likely have this effect as well. Therefore, growth should be monitored during treatment with stimulants, and patients who are not growing or gaining height or weight as expected may need to have their treatment interrupted. Seizures There is some clinical evidence that stimulants may lower the convulsive threshold in patients with prior history of seizures, in patients with prior EEG abnormalities in absence of seizures, and, very rarely, in patients without a history of seizures and no prior EEG evidence of seizures. In the presence of seizures, the drug should be discontinued. Priapism Prolonged and painful erections, sometimes requiring surgical intervention, have been reported with methylphenidate products in both pediatric and adult patients. Priapism was not reported with drug 2018 Christian. All Rights Reserved. 12

13 initiation but developed after some time on the drug, often subsequent to an increase in dose. Priapism has also appeared during a period of drug withdrawal (drug holidays or during discontinuation). Patients who develop abnormally sustained or frequent and painful erections should seek immediate medical attention. Peripheral Vasculopathy, Including Raynaud s Phenomenon Stimulants are associated with peripheral vasculopathy, including Raynaud s phenomenon. Signs and symptoms are usually intermittent and mild; however, very rare sequelae include digital ulceration and/or soft tissue breakdown. Effects of peripheral vasculopathy, including Raynaud s phenomenon, were observed in post-marketing reports at different times and at therapeutic doses in all age groups throughout the course of treatment. Signs and symptoms generally improve after reduction in dose or discontinuation of drug. Careful observation for digital changes is necessary during treatment with ADHD stimulants. Further clinical evaluation (e.g., rheumatology referral) may be appropriate for certain patients. Visual Disturbance Difficulties with accommodation and blurring of vision have been reported with stimulant treatment. Drug Dependence Methylphenidate should be given cautiously to patients with a history of drug dependence or alcoholism. Chronic abusive use can lead to marked tolerance and psychological dependence with varying degrees of abnormal behavior. Frank psychotic episodes can occur, especially with parenteral abuse. Careful supervision is required during withdrawal from abusive use, since severe depression may occur. Withdrawal following chronic therapeutic use may unmask symptoms of the underlying disorder that may require follow-up. Drug Interactions Methylphenidate should not be used in patients being treated (currently or within the proceeding two weeks) with MAO Inhibitors (see CONTRAINDICATIONS, Monoamine Oxidase Inhibitors). Because of possible effects on blood pressure, Methylphenidate should be used cautiously with pressor agents. Methylphenidate may decrease the effectiveness of drugs used to treat hypertension. Methylphenidate is metabolized primarily to methylphenidateic acid by de-esterification and not through oxidative pathways. Human pharmacologic studies have shown that racemic methylphenidate may inhibit the metabolism of coumarin anticoagulants, anticonvulsants (e.g., phenobarbital, phenytoin, primidone), and tricyclic drugs (e.g., imipramine, clomipramine, desipramine). Downward dose adjustments of these drugs may be required when given concomitantly with methylphenidate. It may be necessary to adjust the dosage and monitor plasma drug concentration (or, in case of coumarin, coagulation times), when initiating or discontinuing methylphenidate Christian. All Rights Reserved. 13

14 Carcinogenesis/Mutagenesis In a lifetime carcinogenicity study carried out in B6C3F1 mice, methylphenidate caused an increase in hepatocellular adenomas and, in males only, an increase in hepatoblastomas, at a daily dose of approximately 60 mg/kg/day. This dose is approximately 30 times and 4 times the maximum recommended human dose on a mg/kg and mg/m2 basis, respectively. Hepatoblastoma is a relatively rare rodent malignant tumor type. There was no increase in total malignant hepatic tumors. The mouse strain used is sensitive to the development of hepatic tumors, and the significance of these results to humans is unknown. Methylphenidate did not cause any increases in tumors in a lifetime carcinogenicity study carried out in F344 rats; the highest dose used was approximately 45 mg/kg/day, which is approximately 22 times and 5 times the maximum recommended human dose on a mg/kg and mg/m2 basis, respectively. In a 24-week carcinogenicity study in the transgenic mouse strain p53+/-, which is sensitive to genotoxic carcinogens, there was no evidence of carcinogenicity. Male and female mice were fed diets containing the same concentration of methylphenidate as in the lifetime carcinogenicity study; the high-dose groups were exposed to mg/kg/day of methylphenidate. Methylphenidate was not mutagenic in the in vitro Ames reverse mutation assay or in the in vitro mouse lymphoma cell forward mutation assay. Sister chromatid exchanges and chromosome aberrations were increased, indicative of a weak clastogenic response, in an in vitro assay in cultured Chinese Hamster Ovary (CHO) cells. Methylphenidate was negative in vivo in males and females in the mouse bone marrow micronucleus assay. Impairment of Fertility Methylphenidate did not impair fertility in male or female mice that were fed diets containing the drug in an 18-week Continuous Breeding study. The study was conducted at doses up to 160 mg/kg/day, approximately 80-fold and 8-fold the highest recommended dose on a mg/kg and mg/m2 basis, respectively. Pregnancy Methylphenidate has been assigned pregnancy category C, which means Risk not ruled out: Animal reproduction studies have shown an adverse effect on the fetus and there are no adequate and wellcontrolled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks. Adverse Reactions Nervousness and insomnia are the most common adverse reactions but are usually controlled by reducing dosage and omitting the drug in the afternoon or evening. Other reactions include hypersensitivity (including skin rash, urticaria, fever, arthralgia, exfoliative dermatitis, erythema multiforme with histopathological findings of necrotizing vasculitis, and thrombocytopenic purpura); anorexia; nausea; 2018 Christian. All Rights Reserved. 14

15 dizziness; palpitations; headache; dyskinesia; drowsiness; blood pressure and pulse changes, both up and down; tachycardia; angina; cardiac arrhythmia; abdominal pain; weight loss during prolonged therapy; libido changes. There have been rare reports of Tourette s syndrome. Toxic psychosis has been reported. Although a definite causal relationship has not been established, the following have been reported in patients taking this drug: serotonin syndrome in combination with serotonergic drugs, rhabdomyolysis, instances of abnormal liver function, ranging from transaminase elevation to severe hepatic injury; isolated cases of cerebral arteritis and/or occlusion; leukopenia and/or anemia; transient depressed mood; aggressive behavior; a few instances of scalp hair loss. Very rare reports of neuroleptic malignant syndrome (NMS) have been received, and, in most of these, patients were concurrently receiving therapies associated with NMS. In a single report, a 10-year-old boy who had been taking methylphenidate for approximately 18 months experienced an NMS-like event within 45 minutes of ingesting his first dose of venlafaxine. It is uncertain whether this case represented a drug-drug interaction, a response to either drug alone, or some other cause. In children, loss of appetite, abdominal pain, weight loss during prolonged therapy, insomnia, and tachycardia may occur more frequently; however, any of the other adverse reactions listed above may also occur. Psychotherapy Psychotherapy should always be part of a comprehensive treatment plan for ADHD. Communication- Focused Therapy (CFT) as it was developed by the author focuses on internal and external communication patterns which has shown to be helpful in ADHD. (Haverkampf, 2017a, 2017c, 2017b) Dr, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. The author can be reached by at jonathanhaverkampf@gmail.com or on the websites and Christian. All Rights Reserved. 15

16 References Haverkampf, C. J. (2017a). ADHD and Psychotherapy (2). Retrieved from Haverkampf, C. J. (2017b). Communication-Focused Therapy (CFT) (2nd ed.). Dublin: Psychiatry Psychotherapy Communication Publishing Ltd. Haverkampf, C. J. (2017c). Communication-Focused Therapy (CFT) for ADHD. J Psychiatry Psychotherapy Communication, 6(4), Haverkampf, C. J. (2018). An Overview of Psychiatric Medication (3rd ed.). Dublin: Psychiatry Psychotherapy Communication Publishing Ltd Christian. All Rights Reserved. 16

17 This article is solely a basis for academic discussion and no medical advice can be given in this article, nor should anything herein be construed as advice. Always consult a professional if you believe you might suffer from a physical or mental health condition. Neither author nor publisher can assume any responsibility for using the information herein. Trademarks belong to their respective owners. No checks have been made Christian. All Rights Reserved Unauthorized reproduction and/or publication in any form is prohibited Christian. All Rights Reserved. 17