ADHD

Question 1

“Types” of ADHD

Answer 1

Question 2

Tourette’s disease exists on a spectrum with two other disorders:

Answer 2

ADHD and OCD

The three disorders are often seen in various combinations within a family history.

Question 3

The stimulants used to treat ADHD. . .

Answer 3

. . . often make tics worse

So, be mindful of this when treating a patient with comorbid ADHD and Tourette’s

Question 4

Diagnostic criteria for ADHD

Answer 4

• 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

Question 5

Which type of ADHD tends to affect boys more than girls?

Answer 5

Hyperactive-imulsive (ADHD-HI)

Question 6

Characteristics of inattentive type ADHD

Answer 6

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

Question 7

Characteristics of “hyperactivity” in ADHD

Answer 7

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

Question 8

Characteristics of impulsivity in ADHD

Answer 8

Blurting out answers

Difficulty waiting in line or for one’s turn

Interrupting

Talking excessively without an appropriate respose to a given social situation

Question 9

Diagnosis of ADHD in adults

Answer 9

Same criteria as for children, but a lower threshold of symptoms (5 instead of 6) is sufficient for reliable diagnosis

Question 10

Does ADHD go away with age?

Answer 10

Sometimes.

But there is not a specific age range at which it fades, and many cases will continue into adulthood

Question 11

Dorsal anterior cingulate gyrus

Answer 11

Involved in slecting what an individual focuses on

One of the areas implicated in ADHD pathophysiology (decreased dopaminergic and noradrenergic signaling)

Question 12

Dorsolateral prefrontal cortex

Answer 12

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)

Question 13

Prefrontal motor cortex

Answer 13

Involved in inhibition of motor action

Appears to account for the increased motor activity in ADHD

Question 14

___ and/or ___ are often associated with ADHD

Answer 14

oppositional defiant disorder and/or conduct disorder are often associated with ADHD

Question 15

Early bipolar disorder mimicing ADHD

Answer 15

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

Question 16

___ is a potentially reversible cause of hyperactivity in children, and this should always be ruled out prior to diagnosing a child with ADHD

Answer 16

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.

Question 17

First-line treatments for ADHD

Answer 17

• 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)

Question 18

Side effects of stimulants for ADHD

Answer 18

• Decreased appetite
• Initial insomnia
• Irritability
• Dysphoria
• Headache
• May lead to development of tics

Question 19

Both stimulants and atomoxetine can decrease. . .

Answer 19

. . . appetite

So monitoring height/weight for growth is essential

Remember, these are kids! Growth is the 6th vital sign.

Question 20

Second-line treatments for ADHD

Answer 20

• 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

Question 21

__ are used to treat tic-predominant Tourette syndrome while __ are used to treat patients with concurrent Tourette syndrome and attention deficit hyperactivity disorder.

Answer 21

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.

Question 22

Third-line treatments for ADHD

Answer 22

• 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

Question 23

Age and 1st line therapy for ADHD

Answer 23

For kids 5 years old or younger, behavioral therapy is first line

For kids 6 years old or older, stimulants are first line