ADHD Flashcards by Annika Larson

DSM-5 definition

Persistent pattern of inattention or hyperactivity-impulsivity that clearly interferes with or reduces academic, social, or occupational functioning/development

Must occur for >6 months

Symptoms are present before age 12 and must be present in more than one setting

Must have ≥ 6 symptoms of inattention or hyperactivity-impulsivity

Criteria changes to ≥ 5 for inattention if developed after age 17

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inattention

Fails to focus on details, careless mistakes
Difficulty maintaining attention
Inability to listen when spoken to directly
Inability to follow instruction
Fails to finish schoolwork/other tasks
Trouble organizing schoolwork/other activities
Avoids/dislikes/reluctant to engage in activities requiring continuous attention
Loses items necessary for activities
Easily diverted by external stimuli
Frequently forgets daily activities

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Hyperactivity/impulsivity

Fidgets with hands or feet; squirms in seat
Inability to remain seated when necessary
Runs/climbs in unacceptable situations
Unable to play or engage in quiet, leisure activities
Often “on the go” or acts as if “driven by a motor”
Excessively talks
Impulsively blurts out answers
Difficulty waiting their turn
Interrupts activities or conversations of others; intrudes or takes over for them

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infancy symptoms

Difficulty being soothed; fidgety, crying
Feeding problems; poor sucking, crying during feedings, needing to be fed frequently
Short periods of sleep; little sleep
When crawling, constant motion

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School age symptoms

Constantly “on the go”; unable to stay seated; explosive and irritable
Not able to play quietly or politely
Easily distracted; doesn’t complete tasks
Impulsive, unable to wait their turn
May appear accident-prone
Disorganized – constantly forgetting

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Adolescence symptoms

Procrastination
Disorganization
Forgetfulness
Inattention
Over-reactive
Reckless behaviors; risky driving

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Hyperactivity in adulthood

Inability to sit still through class/work meetings
Excessive talking
Need to get to places quickly

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Impulsivity in adulthood

Frequent job changes
Low frustration tolerance
Unstable relationships with friends/family

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inattentive in adulthood

Poor time management/motivation
Forgetfulness
Excessive mistakes
Poor concentration

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Neuropsychiatric EEG-based Assessment Aid system

Medical device that can assist in ADHD diagnosis between ages 6-17
Test is 15-20 minutes long and measures ratio between theta and beta waves
A higher theta/beta ratio has been found in children and adolescents with ADHD

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EEG should be used

to rule out absence seizures

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Risk factors

Family hx of ADHD
Perinatal stress
Very low birth weight
Maternal smoking during pregnancy
TBI
Severe early oxygen deprivation
Adverse parent-child relationships

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Heritability

4-8 fold increase if 1st degree relative
1/3 of parents with ADHD will have a child with ADHD
Twin studies: 90% concordance
Siblings of hyperactive children are twice as likely to get dx with ADHD

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Dopamine gene polymorphisms

DA transporter gene
NE transporter gene

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Dopamine Pathophysiology

Dysfunction in DAT
Leads to decreased DA

Impairs attention, mood and arousal regulation, and ability to resist distractions

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Two most common co morbidities

Oppositional defiant disorder

Conduct Disorder

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Associated comorbidities

Oppositional defiant disorder
Conduct Disorder
Disruptive mood dysregulation disorder
Substance use/misuse is quite common
Psychiatric conditions
Learning disorders
Sleep disorders

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First line treatment

MPH or AMP
age 4-5 -behavioral therapy

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second line treatment

Ages 4-5: MPH
Ages 6-18: Atomoxetine, GXR, CLON-XR

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Third line treatment

Bupropion, TCA, or alpha2-agonist (4th line)

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Need for medication can be assessed if

symptom free for 1 year

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T/F drug holidays should be attempted frequently

True

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Family-focused non-pharm

Parents attend 10-20 sessions (1-2 hours) with occasional booster sessions
Includes behavioral parenting training (strategies to use at home to improve compliance with commands) and behavioral interventions (positive reinforcement, time-out, response cost, token economy)

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School focused non-pharm

Behavioral classroom management includes tips for teacher to implement in order to improve attention and productivity. May transition to smaller classroom +/- behavior plan

Child-focused non-pharm

Group or office based weekly interventions to focus on peer interactions and relationships

Stimulants -CII

Methylphenidate products Amphetamine products

FDA approved non stimulants

Atomoxetine Guanfacine XR Clonidine XR

Not FDA approved

Bupropion SNRIs TCAs

MPH MOA

CNS stimulant; selectively inhibits reuptake of DA and NE Increase release of catecholamines Specifically blocks DAT/carrier proteins Inhibits MAO

MPH pharmacokinetics

Time to peak may be delayed by high-fat breakfast

MPH dosing

Do not give doses within 6 hours of bedtime; avoids insomnia May give IR formulations as “breakthrough” or “wear off” dosing along with longer acting formulations

Concerta

Outer coat = 22% of drug in IR formulation Semipermeable membrane absorbs water As water is absorbed, the push compartment expands Low concentration drug is expelled Mid-day high concentration drug is expelled

Aptensio XR

IR (40%) and ER (60%) components

Two peaks in surge levels

Metadate, Ritalin, Concerta, Focalin

Quilivant caveats

Contains benzoic acid which is a metabolite of benzyl alcohol; potential for allergic rxn

concerta caveat

most likely will find capsule in stool

Daytrana caveat

Apply to hip, leave on for 9 hours patch has higher bioavailability (lower first pass)

AMP MOA

Stimulates release of DA and NE Blocks DA and NE reuptake

AMP Pharmacokinetics

Time to peak may be delayed by high-fat breakfast Hepatic metabolism via CYP2D6 to two active metabolites Lisdexamfetamine is prodrug; converted to dextroamphetamine

AMP dosing

Do not give doses within 6 hours of bedtime; avoids insomnia May give IR formulations as “breakthrough” or “wear off” dosing along with longer acting formulations

CI for all stimulants

Cardiovascular instability Hyperthyroidism Glaucoma Agitated states History of drug abuse Within 14 days of MAO-I

Box warning for all stimulants

Potential for abuse Can cause sudden cardiac death in those with pre-existing conditions

Precautions all stimulants

HTN/tachycardia [modest increase of 2-4mmHg and 3-6bpm] Psychiatric ADE; exacerbation of psychosis, induction of mania/hypomania Long-term growth suppression – controversial [some indicate up to 1cm/year with continuous tx] Seizures; stimulants lower seizure threshold Visual disturbances such as blurred vision Tics both motor and phonic

Stimulant class-wide side effects

Appetite suppression Insomnia GI distress Irritability Headache

DDI stimulants

Psychostimulants Antihypertensives MAOi TCA Antacids opioids

Class-wide stimulants monitoring

At baseline and with each follow-up Appetite, BP, HR, weight Baseline & annual (children) Height

Atomoxetine MOA

inhibits reuptake of NE

Atomoxetine PK/PGx

CYP2D6 poor metabolizers experience and increase in half-life from the normal 5 hours to 24 hours Active metabolites have a half-life of 6-8 hours and can increase to 34-40 hours

Atomoxetine CI

Within 14 days of MAO-I, glaucoma, pheochromocytoma, CV disease

Atomoxetine warnings

BW for increased suicidality; bolded warning for potential liver injury

Atomoxetine AE

GI discomfort, HA, insomnia, irritability, loss of appetite, nausea, small increase in BP

Atomoxetine DDI

CYP2D6 inhibitors increase atomoxetine, empiric dose decrease warranted

Clonidine XR (Kapvay) and Guanfacine XR (Intuniv) MOA

postsynaptic alpha2 receptor agonist in the prefrontal cortex (PFC) This increases noradrenergic tone and promotes NE firing from locus ceruleus

Clonidine XR (Kapvay) and Guanfacine XR (Intuniv) warnings

hypotension, bradycardia, heart block, syncope, combination with other CNS depressants or medications that lower HR

Clonidine XR (Kapvay) and Guanfacine XR (Intuniv) ADEs

Can occur with first dose Sedation, hypotension, dizziness (tolerability develops)

Clonidine XR (Kapvay) and Guanfacine XR (Intuniv) DDIs

Mirtazapine --> Inhibits alpha2 antihypertensive effects CYP3A4 inhibitors --> Empiric guanfacine dose reduction required

Pregnancy

Stimulants should be avoided during pregnancy

Lactation

refrain from breastfeeding