ADHD

Question 1

Etiology

Answer 1

Genetic: concordance rate of 50% in first degree, DRD4 gene
Biochemical: food allergies, heavy metal toxins, high carb diets
Environmental: prenatal (prematurity, LBW, exposure to toxins)
-family (neglect, high EE, family conflict)
-head trauma

66% of children have significant sx in adulthood

Question 2

Presentation in Adults

Answer 2

hyperactivity - wane
inattention, impulsivity, disorganisation more in adults

hedonistic behaviour, recklessness, gambling, substance use, depression, anxiety

methylphenidate
dexamphetamine
ticks severe anxiety - atomoxetine - NDRI

Question 3

Management in Adults

Answer 3

1st line Tx
-Methylphenidate (Ritalin/ER Concerta) - titration from lowest possible dose i.e. Ritalin 5-10mg 3-4x daily or Concerta 18mg mane
-Dexamphetamine at 10mg/day
-Atomoxetine (NRI)

2nd line
-Atomoxetine, buproprion, clonidine

Question 4

Management in Children

Answer 4

behavioural therapy and medication
methylphenidate
dexamphetamine
clonidine guanfacine with anxiety, insomnia

Question 5

Issues in prescribing ADHD meds

Answer 5

Pre-treatment
-diagnostic clarification. Often comorbid and comorbidity should be treated optimally
-use ADHD questionnaire e.g. ADHD self report scale
-collateral and school reports are important parts of ax
-medical evaluation to rule out cardiac disease
-hx of psychosis or substance use that are contraindications or cautions for stimulants

Treatment issues
-1st line stimulant
-methylphenidate or dexamphetamine immediate or extended release
-monitor for SES - increase anxiety, insomnia, agitation, loss of appetite
-tics can occur and may need clonidine or guanfacine as single agent or in combination
-stop stimulant if severe tics
-start low and go slow. 60mg max of methyl and dex. Lisdex 20-70mg (slow release dex)

Medicolegal -
-authority prescribing - check local medicolegal regulations
-buproprion as non stimulant

Post treatment
-risk of diversion/comorbid substance use
-weight and BP
-ECG 6 monthly as needed
-check doctor shopping program if prescription misuse suspected

Question 6

Non pharm in adult ADHD

Answer 6

Diet - nutritional deficiencies - iron VIt D, Omega 3 fatty acids

Exercise - enhances attention and concentration (hippocampal neurogenesis)

Lifestyle - moderate alcohol, avoid cannabis (amotivational), smoking (vascular brain involvement)

Sleep hygiene, sleep restriction (circadian rhythm dysfunction associated with ADHD), OSA mx

CBT - procrastination, anxiety, comorbid depression, negative schemas, mindfulness to manage hyperactivity or anxiety

Practical strategies - diary, reminders, mobile alarms

Software and apps for optimal performance

neurofeedback - uses operant conditioning principles to create sustained neuroplastic change

Question 7

Managing comorbid substance use disorder

Answer 7

If stabilised >3/12 abstinence:
evaluate/discuss misuse of stimulants
Treat with Concerta, atomoxetine or buproprion if high misuse potential