ADHD

Question 1

Overview of ADHD

Answer 1

higher rate if diagnosed in a first degree relative
etiology is multifactorial (environment, genetics, physiological)

Question 2

Clinical course

Answer 2

One third of children with ADHD will have the diagnosis in adulthood

increased risk of substance use and antisocial personality disorder if ADHD is left untreated

Question 3

ADHD diagnosis criteria

Answer 3

For each domain must have 6 symptoms

for older adolescents and adults (17 years and older), at least 5 symptoms are required for either of the two specifiers
several inattentive or hyperactive symptoms must be present prior to age 12 years

inattentive and hyperactive symptoms must be present in two or more settings

Question 4

Inattention symptoms
must have 6 present

Answer 4

fail to have close attention to detail
doesn’t seem to listen
difficulty sustaining attention in tasks
doesn’t follow instructions
difficulty organizing tasks
loses things necessary for activities
easily distracted
forgetful in daily activity

Question 5

Hyperactive and impulsivity symptoms
must have 6 present

Answer 5

fidgets
leaves seat
runs about
unable to engage in activity quietly
talks excessively
blurts out an answer
difficulty waiting their turn
interrupts or intrudes on others

Question 6

Stimulant dosing

Answer 6

Dose response effects seen in a short period of time
IR formula is prefered in patients weighing more than 16kg
avoid giving dose too late in the day
Dont use two different stimulants, instead use two different dosage forms of the same stimulant

Question 7

Mydayis (mixed amphetamine salts)

Answer 7

max dose is 25mg or 12.5mg (13-17yo) if CrCl is less than 30-15ml/min

Question 8

Daytrana (methylphenidate)

Answer 8

Patch form
do not give the patch if patient has tried oral methylphenidate and failed that therapy

Question 9

Vyvanse (lisdexamfetamine)

Answer 9

Prodrug converted to dextroamphetamine

Question 10

Jornay PM

Answer 10

Take dose in the evening between 6:30pm and 9:30pm

Question 11

Stimulant side effets

Answer 11

Appetite loss
sleep disturbances
Priapism (prolonged erection)
hallucinations
headaches

Question 12

Stimulants common adverse effects and management

Answer 12

reduced appetitie - get high calorie meals when stimulant effects are low

stomach ache - take on full stomach

insomnia - take dose earlier in the day

headache - divide dose

rebound symptoms - longer acting formula

irritability, jitteriness - reduce dose and assess for another mental health disorder

Question 13

Stimulants UNCOMMON adverse effects

Answer 13

Hallucinations - d/c stimulant reassess diagnosis

Risk for sudden cardiac death - assess patients risk of cardiac abnormalities

Question 14

Stimulant monitoring

Answer 14

appetite, behavior, blood pressure, growth rate, heart rate, sleep, ECG

Question 15

Alpha 2 agonists

Answer 15

Guanfacine ER - 3A4 substrate

Clonidine ER - dosed twice daily

Must taper to d/c to avoid rebound hypertension

SE: decreased HR and BP, orthostasis, somnolence, dizziness, rebound hypertension if abrupt stop

Question 16

Norepinephrine reuptake inhibitors and SE

Answer 16

Atomoxetine - 2D6 substrate, weight base dosing >70kg give 40mg once daily, max 100mg

Viloxazine - capsules - swallow whole or put in applesauce, 2D6/UGT substrate; strong 1A2 Inhibitor

SE: increased HR and BP, increased suicidal thinking

Question 17

Bupropion

Answer 17

Not FDA approved for ADHD
2D6 inhibitor
contraindicated in seizure disorders and eating disorders

Question 18

AAP guidelines for preschool age

Answer 18

First line is parent training in behavior management
second line is training and FDA approved medication
First line is methylphenidate

Question 19

AAP guidelines for elementary and middle school age

Answer 19

First line is FDA approved medication and parent training in behavior management
First line - stimulants
Second line: atomoxetine, guanfacine ER, clonidine ER

Question 20

AAP guidelines for adolescents (age 12-18)

Answer 20

First line is FDA approved medication and may consider parent training therapy
Only guanfacine ER and clonidine ER have evidence as adjuncts to stimulants

Question 21

ADHD guidelines for adults

Answer 21

Methylphenidate or lisdexamfetamine

• dextroamphetamine (if unable to tolerate lisdexamfetamine long half life)

Atomoxetine (if no symptoms response to above agents)