ADD Flashcards
ADD- aka
Minimal Brain Dysfunction
Epidemiology
Childhood prevalence of 5% Adult persistence of 2.5% M:F of 3:1 Risk factors Perinatal: maternal smoking, substance abuse, obstetrical complications, malnutrition, toxic or viral exposure Imaging studies
Attention Deficit Hyperactivity Disorder- Key
KEY: pattern of extreme inattentiveness and/or restlessness
Occurs in at least two settings for at least 6 months with onset before the age of 12 with at least 6 symptoms
3 types: inattentive type; hyperactive-impulsive type; combined
ADHD symptoms and general treatment
Symptoms of hyperactivity are usually are very obvious by first grade when children are asked to sit still and focus in class.
Symptoms need to be present before age 7.
Treatment of choice is stimulants such as methylphenidate.
Adults can have difficulties at work and thus may need meds.
Estimates are that 60% of the cases persist until adulthood.
3-10% of young & school age children
Male-female ratio is 4:1
Without treatment there are more arrests, suicide attempts, substance abuse, car accidents and poor school/work performance.
Inattention – 1A
Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.
Often has trouble keeping attention on tasks or play activities.
Often does not seem to listen when spoken to directly.
Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).
Often has trouble organizing activities.
Often avoids, dislikes, or doesn’t want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework).
Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools).
Is often easily distracted.
Is often forgetful in daily activities.
Hyperactivity – Impulsivity 1B
Often fidgets with hands or feet or squirms in seat.
Often gets up from seat when remaining in seat is expected.
Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless).
Often has trouble playing or enjoying leisure activities quietly.
Is often “on the go” or often acts as if “driven by a motor”.
Often talks excessively.
Often blurts out answers before questions have been finished.
Often has trouble waiting one’s turn.
Often interrupts or intrudes on others (e.g., butts into conversations or games).
DSM-V Criteria for ADHD
Six or more of the symptoms of inattention have been present for at least 6 months to a point that is disruptive and inappropriate for developmental level
Six or more of the symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level
Symptoms that cause impairment were present before age 12 years.
Impairment from the symptoms is present in two or more settings (e.g. at school/work and at home).
There must be clear evidence of significant impairment in social, school, or work functioning.
The symptoms do not happen only during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder. The symptoms are not better accounted for by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).
two types of ADHD are identified:
ADHD,Inattentive Type
ADHD, Predominantly Hyperactive-Impulsive
ADHD,Combined Type
Making a longer half life drug
Change the rate it dissolves
Osmotically released Oral Stimulates
Transdermal
Or just give multiple dosing
Pharmacological Actions
Methylphenidate
Increased postsynaptic dopamine by blocking it’s reuptake
Amphetamine
Inhibits multiple monoamine transport systems
Increases release from synaptic vesicles
Lesdexamfetamine
Tricks of the trade
Starter doses Managing the afternoon crash Drug Holidays Short half life drug of short term focus Managing sleep
Principle side effects
Appetite suppression
Irritability
Exacerbation of Tic symptoms
?Psychosis
Drug diversion
Taking a drug that was not prescribed to you
In New York it is illegal but not criminal
Opiates, sedatives, then stimulants.
More ADHD facts
Impairment must be in more than one setting.
Home AND school or work
Etiology – Probably multi-factorial – genetic, environmental, neurobiological and social
Quantitative MRI show prefrontal cortex, basal ganglia & cerebellar abnormalities
Co-morbid disorders are common, seizures, Conduct D/O, Oppositional Defiant D/O or learning disorders
Clinical Management
Stimulants are effective for 80% of patients and are first line treatment.
- Methylphenidate or mixed amphetamine salts
Weight-based dosing. Typical 0.5 – 1 mg/kg/day
Side Effects: Decreased appetite, irritability, insomnia, weight loss, abdominal pain & misuse, abuse/diversion are concerns – Monitor growth & weight & get feedback from teachers.
Nonstimulants – atomoxetine
Alpha 2 agonists – clonidine, guanfacine
Rarely tricyclics or bupropion
Start at lowest recommended dose and increase slowly, as tolerated and indicated
Treatment with stimulants has decreased risk for substance abuse.
