ADHD Flashcards
“Types” of ADHD
Tourette’s disease exists on a spectrum with two other disorders:
ADHD and OCD
The three disorders are often seen in various combinations within a family history.
The stimulants used to treat ADHD. . .
. . . often make tics worse
So, be mindful of this when treating a patient with comorbid ADHD and Tourette’s
Diagnostic criteria for ADHD
- Persistent pattern of inattention and/or hyperactivity/impulsivity
- Begins before age 12
- Present for at least 6 months
- Observed in more than one setting (school, home, etc) with accounts from reliable caretakers
Which type of ADHD tends to affect boys more than girls?
Hyperactive-imulsive (ADHD-HI)
Characteristics of inattentive type ADHD
Failure to pay attention to details
Failure to focus attention when performing tasks
Failure to follow through with instructions
Impaired ability to organize tasks
Misplacing items
Becoming easily distracted by external stimuli
Characteristics of “hyperactivity” in ADHD
Increased fidgeting of the hands/feet
Inability to stay seated in a clasroom setting
Being unduly noisy during playtime activities
Persistent pattern of increased motor activity not significantly modified by social context
Characteristics of impulsivity in ADHD
Blurting out answers
Difficulty waiting in line or for one’s turn
Interrupting
Talking excessively without an appropriate respose to a given social situation
Diagnosis of ADHD in adults
Same criteria as for children, but a lower threshold of symptoms (5 instead of 6) is sufficient for reliable diagnosis
Does ADHD go away with age?
Sometimes.
But there is not a specific age range at which it fades, and many cases will continue into adulthood
Dorsal anterior cingulate gyrus
Involved in slecting what an individual focuses on
One of the areas implicated in ADHD pathophysiology (decreased dopaminergic and noradrenergic signaling)
Dorsolateral prefrontal cortex
Involved with sustaining attention on a topic, as well as various other executive functions
One of the areas implicated in ADHD pathophysiology (decreased dopaminergic and noradrenergic signaling)
Prefrontal motor cortex
Involved in inhibition of motor action
Appears to account for the increased motor activity in ADHD
___ and/or ___ are often associated with ADHD
oppositional defiant disorder and/or conduct disorder are often associated with ADHD
Early bipolar disorder mimicing ADHD
Childhood bipolar disorder can have symptoms of restlessness and distractability, bu there will also be an affective component
ie, elevated mood, grandiosity, decreased need for sleep
___ is a potentially reversible cause of hyperactivity in children, and this should always be ruled out prior to diagnosing a child with ADHD
Lead toxicity is a potentially reversible cause of hyperactivity in children, and this should always be ruled out prior to diagnosing a child with ADHD
Blood lead test is the initial evaluation for this.
First-line treatments for ADHD
- Stimulant: (70-80% response rate, rapid on-off with effects wearing off at end of day)
- Methylphenidate
- Amphetamine
-
Atamoxitine: (gradual onset of action over 2-3 weeks, once working has 24-hour length of action. May be sedating)
- Selective inhibitor of the presynaptic norepinephrine transporter
- 1st line for patients or families with history of substance abuse OR comorbid anxiety disorders
- Behavioral therapy in conjunction with a medication (never alone, it is not effective alone)
Side effects of stimulants for ADHD
- Decreased appetite
- Initial insomnia
- Irritability
- Dysphoria
- Headache
- May lead to development of tics
Both stimulants and atomoxetine can decrease. . .
. . . appetite
So monitoring height/weight for growth is essential
Remember, these are kids! Growth is the 6th vital sign.
Second-line treatments for ADHD
- Centrally acting alpha agonists
- Guanfenesin
- Clonidine
- May be used with a stimulant or as monotherapy
- Often added on to stimulant therapy to reduce effects of sleep disturbance or agitated behavior
__ are used to treat tic-predominant Tourette syndrome while __ are used to treat patients with concurrent Tourette syndrome and attention deficit hyperactivity disorder.
Dopamine depleters (e.g., tetrabenazine) are used to treat tic-predominant Tourette syndrome while alpha agonists (e.g., guanfacine or clonidine) are used to treat patients with concurrent Tourette syndrome and attention deficit hyperactivity disorder.
Third-line treatments for ADHD
-
Buproprion
- With buproprion, seizures are a contraindication. It may also exacerbate tics due to its pro-dopaminergic action.
-
Imipramine
- With imipramine, blood levels and ECGs are monitored for risk of QT prolongation
Age and 1st line therapy for ADHD
For kids 5 years old or younger, behavioral therapy is first line
For kids 6 years old or older, stimulants are first line
