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Therapeutics (Fall 2024) > ADHD > Flashcards

ADHD Flashcards

1
Q

What is ADHD?

A

Neurodevelopmental disorder, Inattention and disorganization, hyperactivity/impulsivity.

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2
Q

What are the diagnostic test for ADHD?

A

No biological marker or imaging study is diagnostic
for ADHD.

Therefore a CLINICAL diagnosis

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3
Q

What are the diagnositic features of ADHD?

A

Essential feature of ADHD is a persistent pattern of
inattention and/or hyperactivity-impulsivity that
interferes with functioning or development

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4
Q

What are the two main categories of ADHD criteria? (3)

A

Inattention, hyperactivity and impulsivity and combined

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5
Q

Etiology of ADHD?

A

Non entirely know

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6
Q

Risk factors of ADHD

A
  • Low birth weight/prematurity
  • Exposure to smoking during pregnancy
  • Family history of ADHD
  • Perinatal stress
  • Fetal alcohol syndrome
  • Lead poisoning
  • Traumatic brain injury
  • Severe early oxygenation deprivation
  • Adverse parent-child relationships
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7
Q

What is the pathophysiology of ADHD?

A

Anatomical structures:

Delay and rate of cortical thickening contributes to difficulty prioritizing tasks

Lack of connectivity between the prefrontal cortex is associated with lapses in attention and poor impulse control

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8
Q

What is an EEG?

A

Electroencephalography is a method to record an electrogram of the spontaneous electrical activity of the brain.

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9
Q

What is the prevalence of EEG abnormalities in patients with ADHD?

A

90% echibit some abnormalities but this is not diagnositic

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10
Q

What is thought to be the D2 and NE abnormalities?

A
  • Deficit in DA reward pathway impairs brain’s ability to maintain
    attention to dull or repetitive tasks, postpone indulgence,
    regulate mood and arousal, resist distractions
  • NE dysfunction leads to inability to modulate attention, arousal,
    and mood
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11
Q

What occurs due to too little DA and NE?

A
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12
Q

What occurs during moderate release of DA/NE release?

A
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13
Q

What occurs during excessive DA and NE release?

A
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14
Q

What are the S/S of ADHD in infancy? (4)

A
  • Difficulty being soothed because irritability, fidgeting, crying and/or colic
  • Feeding problems including poor sucking, crying during feedings
  • Short periods of sleep or very little sleep
  • When crawling in constant motion
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15
Q

What are the S/S of ADHD in School age children? (5)

A
  • Constantly “on the go”, unable to stay seated or play quietly
  • Easily distracted, trouble completing tasks
  • Impulsive, unable to wait turn, may blurt out answers, needs instant gratification
  • May appear accident prone due to hyperactivity and impulsivity
  • Disorganized, forgetting or losing homework
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16
Q

What are the S/S of ADHD in School age Adulthood? (3)

A
  • Hyperactive symptoms include inability to sit through class/work meetings, excessive
    talking, needs to get to places quickly
  • Impulsive symptoms include frequent job changes, low frustration tolerance,
    unstable interpersonal relationships
  • Inattentive symptoms include poor time management, poor motivation and
    concentration, forgetfulness, excessive mistakes
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17
Q

What are the S/S of ADHD in School age Adolescecne? (2)

A
  • Dominant features include disorganization, forgetfulness, inattention, overreaction
  • Reckless driving and risky behaviour may occur
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18
Q

What age must ADHD symptoms be present in accordance to the DSM5 criteria?

A

age 12

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19
Q

What are some of the assessment of ADHD that can be used?

A

CADDRA guidelines have many that are greattools that involve patients, caregivers

SNAP-IV 26 questionnaire
CADDRA Teacher

Assessment Form are recommended for initial
information gathering in childrne/adolescents suspected of ADHD

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20
Q

What is the clinical course of ADHD in infancy? (2)

A
  • Delay in motor and language development
  • Difficult temperament
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21
Q

What is the clinical course of ADHD in Preschool Age? (3)

A
  • Usually when initial symptoms start
  • Hyperactive/impulsive symptoms dominate with tendency for intense temper tantrums
  • Symptoms are less stable and vary between settings
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22
Q

What is the clinical course of ADHD in School Age? (5)

A
  • When initial diagnosis usually occurs
  • Boys preset with hyperactivity/impulsive symptoms that are more noticeable
  • Girls present with more inattentive symptoms
  • Hyperactive/impulsive symptoms persist whereas inattentive symptoms develop later
  • Oppositional and socially aggressive behaviours begin to emerge
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23
Q

What is the clinical course of ADHD in Adolescene? (4)

A
  • Hyperactive symptoms begin to decline, impulsive and inattentive symptoms persist
  • Inattentive symptoms may be more prominent
  • Oppositional and socially aggressive behaviours continue to develop
  • Substance use disorders may emerge
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24
Q

What is the clinical course of ADHD in Adulthood? (3)

A
  • More prevalent in males than females (1.6:1)
  • Inattentive symptoms are most common
  • Hyperactive/impulsive symptoms associated with higher bipolar/psychosis
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25
Q

What are the most prevalent Co-Morbidities associated with ADHD?

A

Conduct or behavioural problems
Anxiety
Depression
ODD
epilepsy 2x3 more likely
SUD 2.5 more likely
learning disorders

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26
Q

What are the consequences of untreated ADHD? (3)

A
  • ↓ social, educational, vocational, and self-care
    functioning
  • ↑ rates of accidental injury
  • ↑ time and energy to cope with ADHD related
    challenges
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27
Q

What are the goals of therapy with ADHD treatment? (6)

A
  • Eliminate or significantly decrease the core ADHD
    symptoms
  • Improve behavioural, academic, and/or
    occupational performance
  • Improve self-esteem
  • Improve social functioning
  • Minimize adverse drug effects
  • Improve quality of life
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28
Q

What are the treatment guidelines with regards to ADHD (General)

A

Based on most current evidence

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29
Q

When might behavioural therapies be more appropriate for ADHD?

A

Behavioral therapies can be the initial treatment if
symptoms are mild, diagnosis is unclear, or
medication is not preferred by parents

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30
Q

What is the most effective treatment for ADHD?

A

Behavioral and pharmacological

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31
Q

What are the tiers of holistic ADHD care for

A

Adequate education, behavioural or occupational interventions. psychological treatment, educational accommodation, medical management

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32
Q

What are the Family focused interventions?

A

Behavioral parent training:
behavior modification
principles for parents to
implement at home to
improve compliance with
parent’s commands (ex.
Parent child interaction
therapy)

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33
Q

What are the school focused interventions?

A

Behavioral classroom
management: provides
principles for teacher to
implement in order to
improve attention, work
productivity, compliance to
classroom rules.

Other examples: smaller
classrooms, preferred
seating, behavior plans

34
Q

WHat are the Child focused interventions ofr ADHD?

A

Behavioral peer
interventions: focus on
peer interactions and
relationships

35
Q

What are the CBT focused therapies for ADHD?

A

Reduce core ADHD
symptoms in short term
but additional long-term
studies needed. Tailors
treatment to individual’s
behaviours.

36
Q

What is the goal of medication principles for treatment?

A

Meds should target symptoms that cause
impairment

37
Q

What were the results of the atomoxetine vs concerta trial?

A

That concerta/stimulants may be better in the treatment of ADHD, but atomoxetine can serve as an alternative for treatment.

38
Q

What were the strengths of the Atomoxetine vs Concerta

A

Clinically relevant outcomes
Effort made to ensure bnding maintinaed
All treatment groups balanced
Lost to followup similar
Last observation carried forward used for patients that left early

39
Q

What were the limitations of the Atomoxetine vs concerta trial?

A
40
Q

What are the 2 classes of ADHD medications?

A

Stimulants and non-stimulants

41
Q

What are the non-stimulants?

A
  • Atomoxetine
  • Guanfacine
  • Clonidine
  • Bupropion
  • Others
42
Q

What are the stimulants?

A
  • Methylphenidate products
  • Amphetamine products
43
Q

What is the MOA of methylphenidate?

A
  • Inhibits the presynaptic reuptake of DA and NE by
    specifically blocking transport proteins
  • DA appears to have larger role than NE
  • Leads to increased sympathomimetic activity in CNS
  • Limited peripheral activity
44
Q

What is the MOA of amphetamine

A
  • Increase the release of DA
    and NE into the synapses
    from presynaptic nerve terminal
  • Enhance release of NE in
    periphery from adrenergic
    nerve terminals
  • May stimulate the release of serotonin and act as a serotonin agonist (higher doses)
  • Inhibit the reuptake of
    monoamines in extraneuronal space
45
Q

What is the MOA of atomoxetine?

A

NE reuptake inhibitor in the CNS.

46
Q

What is the MOA of Guanfacine?

A

Alpha 2 adrenergic receptor agonists

47
Q

What is the MOA of guanfacine?

A

More selective for the alpha 2a receptor than clonidine

  • Binds to postsynaptic alpha2A receptors in the PFC → improves
    delay related firing of PC neurons
  • Leads to improvement in underlying working memory and behavioural functions
48
Q

Why are long acting stimulants acting as 1st line pharmacotherapy?

A

Better management of lows

49
Q

What are the long acting stimulants?

A

Adderall XR, Vyvanse, Biphentin, Concerta, Foquest, Quillivant

50
Q

By how much are the ADHD symptoms reduced on long acting stimulants?

A

30-40% in 70% of treated patients

51
Q

When is response generally seen in long acting stimulants?

A

1st week for some, adequate trial is 3-4 weeks

52
Q

Are methylphenidate and amphetamines equally efficacious?

A

Yes

53
Q

If treatment failure occurs on long acting stimulants what are the options:

A

Try a different stimulant class, but not short acting.

54
Q

Compared to IR psychostimulants LA?

A

May diminish diversion and rebound ADHD and are associated with better tolerability

55
Q

What are the second line class pharmacotherapy for ADHD?

A

Non-Stimulants

56
Q

What are the 2nd line pharmacotherapy options?

A

atomoxetine, guanfacine XR

57
Q

What is the symptom reduction in ADHD with non-stimulants?

A

25-30%, in 60-70% treated with atomoxetine

58
Q

What are the onset of non-stimulants for 2nd line pharmacotherapy?

A

Onset 2 weeks, max effects seen at 6-8 weeks

59
Q

When are non-stimulants used as first line? (5 main points)

A

If stimulants are contraindicated, intolerable adverse effects develop, comorbid active substance use, severe anxiety, tic disorder present, parents hesitant to initiate stimulants

60
Q

When do we utilize short/intermediate acting psychostimulants utilized?

A

Used to augment long acting formulations early or late in a day or early evening

Sometimes we utilize in children prior to bedtime so they can focus on the act of sleeping

61
Q

Dextroamphetamine products are used to augment long acting ____ products and ___

A

Amphetamine and lisdexamfetamine

62
Q

Methylphenidate products are used to augment ___ extended and controlled release products

A

Methylphenidate

63
Q

What are the 3rd line agents for managing ADHD?

A

Bupropion, clondine, imipramine, modafinil

64
Q

Are AP utilized in ADHD?

A

used for comorbidiites commonly seen with ADHD

65
Q

Do we treat ADHD before or after comborbid conditions?

A

After, such as MDD

66
Q

What are the 2 first line amphetamine based psychostimulants?

A

Adderall, vyvanse,

67
Q

What is the one 2nd line amphetamine based stimulants?

A

Dexedrine

68
Q

What are the first line methylphenidate based psychostimulants?

A

Biphentin, concerta, foquest, quillivant

69
Q

What are the second line methylphenidate based psychostimulants?

A

Ritalin SR
Methylphenidate SA

70
Q

What is a special consideration about ritalin SR

A

Ritalin SR has an affect of 8 hours BUT its therapeutic effect does not qualify for it to be a long acting agent.

71
Q

What are the 2nd line selective norepinephrine reuptake inhibitors

A

atomoxetine

72
Q

What are the 2nd line Alpha 2A adrenergic receptor agonist

A

Intuniv XR

73
Q

What is the one major contraindications to all ADHD medications?

A

known hypersensitivity or allergy to products duh..,.

74
Q

What are the precautions to taking all ADHD medications?

A
75
Q

What is to be monitored during treatment with ALL adhd medications?

A
76
Q

What are the true contraindications to psychostimulants? (7)

A
77
Q

What are the precautions with taking psychostimulants?

A
78
Q

What is to be monitored during treatment with psychostimulants?

A
79
Q

What are the specific contraindications to atomoxetine? (8)

A
80
Q

What should be precautioned with atomoxetine (3)

A
81
Q
A

Therapeutics (Fall 2024) (11 decks)

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