6 - ADHD Flashcards
1
Q
Describe ADHD
A
- Most common neurodevelopmental disorder in children
- Unknown cause – genetics, low birth weight, male:female = ~2:1
- 25% of children w/ ADHD have a parent who meet ADHD dx
- Females less likely to have disruptive sx
2
Q
Developmental impact of ADHD across lifespan
A
- 2-5x greater risk of trauma, burns, poisoning
- Substance use disorder 2x greater
- Affects academic problems, social interactions, self-esteem issues throughout life
3
Q
Diagnosis of ADHD
A
- No objective tests/ biological markers for diagnosis
- General mental health screening (to identify comorbidities & differential diagnoses)
- ADHD assessment tool
- Info gathering from parents/ caregivers & teachers and self-assessment
- Exclude medical causes that mimic/ aggravate ADHD sx
- Review lifestyle habits (ex: exercise, high-risk activities, substance use)
4
Q
Describe the core sx of ADHD. How many are needed for a diagnosis?
A
- Need 6/9 sx from either group for diagnosis
- Majority of px are combined subtype instead of primarily inattentive or primarily hyperactive/impulsive
- Inattentive sx – sustained attention problem solving
- Difficulty following through or finishing tasks; disorganization; trouble sustaining mental effort
- Inattentive sx – selective attention
- Pays little attention to detail; makes careless mistakes; doesn’t listen; loses things; forgets things; easily distracted
- Impulsive sx
- Talks excessively; blurts out; interrupts; doesn’t wait one’s turn
- Hyperactive sx
- Fidgets; leaves one’s seat; running/ climbing; constantly “on-the-go”, has trouble playing quietly
5
Q
Goals of therapy for ADHD
A
- Eliminate or significantly decrease ADHD sx
- Improve behavioural, academic, and/or occupational performance
- Improve self-esteem & social functioning
- Minimize adverse effects of medications
- Improve QOL
6
Q
Best tx approach
A
- Non-drug (psychosocial) + medications (ex: stimulants, atomoxetine) to improve QOL & core ADHD sx
- Stimulants & atomoxetine have greatest effect on core sx of ADHD
- Behavioural therapies important for improving social interactions, self-esteem, & common behaviours seen in ADHD; inferior to drug alone at reducing core ADHD sx
- Combination more effective at reducing oppositional behaviour & anxiety and improving social interactions & self-esteem compared to either tx alone
7
Q
Psychosocial interventions for ADHD
A
- Psychoeducation –> educate & empower px/families providing info on ADHD
- Parent management training models –> reinforce positive behaviour, ignore low-level provocative behaviour, provide clear, consistent, & safe responses to unacceptable behaviour
- Social skills training –> perceive & interpret subtle cues & problem-solve in social interactions
- Cognitive behavioural therapy –> focuses on interaction between cognition, emotion, behaviour
- Mindfulness training –> increase mindful attention to own thoughts & actions
8
Q
Medication options for ADHD
A
- Psychostimulant (amphetamine-based or methylphenidate-based)
- Selective norepi reuptake inhibitor (atomoxetine)
- Alpha 2-agonist (clonidine, guanfacine)
- Antidepressant (bupropion, venlafaxine, TCAs)
- Dopaminergic agent (modafinil)
9
Q
Medication guidelines for ADHD
A
- First line = long-acting psychostimulants (Adderall, biphentin, concerta, Vyvanse)
- Dosed once daily; less abuse potential/ diversion; harder to titrate; more expensive
- Second line = long-acting non-psychostimulants (atomoxetine, guanfacine)
- Second line/ adjunctive = short & intermediate-acting psychostimulants (Dexedrine to augment Adderall/ vyvanse, Ritalin to augment biphentin/ concerta)
- Role = PRN for certain activities, augment long-acting preps early or later in day; if long-acting cost prohibitive
10
Q
Describe pt factors that should be considered when selecting a medication for ADHD
A
- Age & individual variation
- Duration of effect required by timing of sx
- Concurrent psychiatric/ medical issues
- Physician/ family/ pt attitudes
11
Q
Describe medication factors that should be considered when selecting a medication for ADHD
A
- MOA, DIs
- Delivery system, duration of action
- Available doses
- Canadian clinical indications
- Affordability, accessibility
12
Q
Describe other considerations that should be made when selecting a medication for ADHD
A
- Combining meds for adjunct effects
- Potential for abuse, misuse, diversion
- Generic formulations
13
Q
Common side effects of ADHD medications
A
- Headache, decreased appetite, increased appetite in evening, insomnia, tics, irritability, rebound hyperactivity
- Most improve w/in 2-3 weeks of continuous use
14
Q
Stimulants & CV risk
A
- Increase BP 3-4 mmHg & HR 1-2 bpm in children/ adolescence
- Monitor BP, HR at baseline & follow-up
- Routine EKG screening not recommended
- Avoid stimulant/ atomoxetine use in those w/ serious heart problems or where BP/HR increase would be problematic
15
Q
ADHD & substance use disorder
A
- Comorbidity of SUG & ADHD is high (25% adults, 50% adolescence)
- LA stimulants may have lower abuse potential than IR products
- Atomoxetine, bupropion, guanfacine options if active SUD
- Oral psychostimulants don’t have the same abuse liability as illicit stimulants (ex: cocaine)
- Alcohol increases SE from stimulants
16
Q
Stimulants & growth
A
- May be associated w/ decreased height at least in first 1-3 years of tx
- Most achieve satisfactory adult height
- Monitor height, weight, BMI at baseline & annually
- If crosses 2 percentile lines –> drug holiday or switch to non-stimulant
17
Q
Advantages of drug “holidays”
A
- May minimize loss of height & weight
- Allow pt & physician to continue to reassess benefits & risks of medication
- Weekend “drug holiday” might work for insomnia or appetite suppression
18
Q
Disadvantages of drug “holidays”
A
- Risks of medication discontinuation may exceed any potential benefit
- Consensus recommendation is that risks, benefits, & alternative coping strategies be discussed & individualized approach taken
19
Q
Stimulants – monitoring
A
- Efficacy (core sx) – response = 1 week; trial = 3-4 weeks
- Safety, common SE (headache, insomnia, anxiety, increased BP/ HR, appetite suppression) – most resolve in 2-3 weeks
- Safety; growth – baseline & annually
20
Q
Non-psychostimulant options
A
- Selective norepi reuptake inhibitor (Atomoxetine)
- Selective alpha 2-adrenergic receptor agonist (Guanfacine)
21
Q
Describe atomoxetine. Indication and monitoring
A
- 25-30% reduction in core sx in 60-70% of people after 6-12-week tx
- Indication = 6 y & older, adolescents, adults w/ ADHD
- Role = no response to stimulant, comorbid anxiety, active SUD
- Suicidal ideation in children/adolescents increases 4/1000; monitor in the first few months
- Monitor efficacy (core sx) – response in 3-4 weeks, trial = 6-12 weeks (slower onset)
- If suicidal thoughts/ behaviours, stop tx
22
Q
Describe alpha 2-adrenergic agonists
A
- Clonidine, guanfacine
- Moderate benefit in children/ adolescence
- Primarily reduce aggression, impulsivity, hyperactivity; less pronounced benefits on inattention
- Combined w/ stimulants – target sleep disruption, aggression, impulsivity, tics
- Monitor efficacy (core sx) – response in 3-4 weeks, trail = 6-12 weeks
- Withdrawal reactions occur if stopped suddenly after long-term use (1-2 months)
- Taper 25% q3-7days to prevent rebound HTN, sedation
23
Q
What other drugs can be used for ADHD?
A
- Antidepressants (bupropion, venlafaxine) – 2nd/3rd line or adjunctive, less effective than stimulants
- Role = comorbid depression, anxiety, enuresis, tic disorders
- Antipsychotics – may negatively affect cognition in ADHD px
