ADHD Flashcards
What is ADHD?
Neurodevelopmental disorder, Inattention and disorganization, hyperactivity/impulsivity.
What are the diagnostic test for ADHD?
No biological marker or imaging study is diagnostic
for ADHD.
Therefore a CLINICAL diagnosis
What are the diagnositic features of ADHD?
Essential feature of ADHD is a persistent pattern of
inattention and/or hyperactivity-impulsivity that
interferes with functioning or development
What are the two main categories of ADHD criteria? (3)
Inattention, hyperactivity and impulsivity and combined
Etiology of ADHD?
Non entirely know
Risk factors of ADHD
- 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
What is the pathophysiology of ADHD?
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
What is an EEG?
Electroencephalography is a method to record an electrogram of the spontaneous electrical activity of the brain.
What is the prevalence of EEG abnormalities in patients with ADHD?
90% echibit some abnormalities but this is not diagnositic
What is thought to be the D2 and NE abnormalities?
- 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
What occurs due to too little DA and NE?
What occurs during moderate release of DA/NE release?
What occurs during excessive DA and NE release?
What are the S/S of ADHD in infancy? (4)
- 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
What are the S/S of ADHD in School age children? (5)
- 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
What are the S/S of ADHD in School age Adulthood? (3)
- 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
What are the S/S of ADHD in School age Adolescecne? (2)
- Dominant features include disorganization, forgetfulness, inattention, overreaction
- Reckless driving and risky behaviour may occur
What age must ADHD symptoms be present in accordance to the DSM5 criteria?
age 12
What are some of the assessment of ADHD that can be used?
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
What is the clinical course of ADHD in infancy? (2)
- Delay in motor and language development
- Difficult temperament
What is the clinical course of ADHD in Preschool Age? (3)
- Usually when initial symptoms start
- Hyperactive/impulsive symptoms dominate with tendency for intense temper tantrums
- Symptoms are less stable and vary between settings
What is the clinical course of ADHD in School Age? (5)
- 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
What is the clinical course of ADHD in Adolescene? (4)
- 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
What is the clinical course of ADHD in Adulthood? (3)
- More prevalent in males than females (1.6:1)
- Inattentive symptoms are most common
- Hyperactive/impulsive symptoms associated with higher bipolar/psychosis
What are the most prevalent Co-Morbidities associated with ADHD?
Conduct or behavioural problems
Anxiety
Depression
ODD
epilepsy 2x3 more likely
SUD 2.5 more likely
learning disorders
What are the consequences of untreated ADHD? (3)
- ↓ social, educational, vocational, and self-care
functioning - ↑ rates of accidental injury
- ↑ time and energy to cope with ADHD related
challenges
What are the goals of therapy with ADHD treatment? (6)
- 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
What are the treatment guidelines with regards to ADHD (General)
Based on most current evidence
When might behavioural therapies be more appropriate for ADHD?
Behavioral therapies can be the initial treatment if
symptoms are mild, diagnosis is unclear, or
medication is not preferred by parents
What is the most effective treatment for ADHD?
Behavioral and pharmacological
What are the tiers of holistic ADHD care for
Adequate education, behavioural or occupational interventions. psychological treatment, educational accommodation, medical management
What are the Family focused interventions?
Behavioral parent training:
behavior modification
principles for parents to
implement at home to
improve compliance with
parent’s commands (ex.
Parent child interaction
therapy)
What are the school focused interventions?
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
WHat are the Child focused interventions ofr ADHD?
Behavioral peer
interventions: focus on
peer interactions and
relationships
What are the CBT focused therapies for ADHD?
Reduce core ADHD
symptoms in short term
but additional long-term
studies needed. Tailors
treatment to individual’s
behaviours.
What is the goal of medication principles for treatment?
Meds should target symptoms that cause
impairment
What were the results of the atomoxetine vs concerta trial?
That concerta/stimulants may be better in the treatment of ADHD, but atomoxetine can serve as an alternative for treatment.
What were the strengths of the Atomoxetine vs Concerta
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
What were the limitations of the Atomoxetine vs concerta trial?
What are the 2 classes of ADHD medications?
Stimulants and non-stimulants
What are the non-stimulants?
- Atomoxetine
- Guanfacine
- Clonidine
- Bupropion
- Others
What are the stimulants?
- Methylphenidate products
- Amphetamine products
What is the MOA of methylphenidate?
- 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
What is the MOA of amphetamine
- 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
What is the MOA of atomoxetine?
NE reuptake inhibitor in the CNS.
What is the MOA of Guanfacine?
Alpha 2 adrenergic receptor agonists
What is the MOA of guanfacine?
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
Why are long acting stimulants acting as 1st line pharmacotherapy?
Better management of lows
What are the long acting stimulants?
Adderall XR, Vyvanse, Biphentin, Concerta, Foquest, Quillivant
By how much are the ADHD symptoms reduced on long acting stimulants?
30-40% in 70% of treated patients
When is response generally seen in long acting stimulants?
1st week for some, adequate trial is 3-4 weeks
Are methylphenidate and amphetamines equally efficacious?
Yes
If treatment failure occurs on long acting stimulants what are the options:
Try a different stimulant class, but not short acting.
Compared to IR psychostimulants LA?
May diminish diversion and rebound ADHD and are associated with better tolerability
What are the second line class pharmacotherapy for ADHD?
Non-Stimulants
What are the 2nd line pharmacotherapy options?
atomoxetine, guanfacine XR
What is the symptom reduction in ADHD with non-stimulants?
25-30%, in 60-70% treated with atomoxetine
What are the onset of non-stimulants for 2nd line pharmacotherapy?
Onset 2 weeks, max effects seen at 6-8 weeks
When are non-stimulants used as first line? (5 main points)
If stimulants are contraindicated, intolerable adverse effects develop, comorbid active substance use, severe anxiety, tic disorder present, parents hesitant to initiate stimulants
When do we utilize short/intermediate acting psychostimulants utilized?
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
Dextroamphetamine products are used to augment long acting ____ products and ___
Amphetamine and lisdexamfetamine
Methylphenidate products are used to augment ___ extended and controlled release products
Methylphenidate
What are the 3rd line agents for managing ADHD?
Bupropion, clondine, imipramine, modafinil
Are AP utilized in ADHD?
used for comorbidiites commonly seen with ADHD
Do we treat ADHD before or after comborbid conditions?
After, such as MDD
What are the 2 first line amphetamine based psychostimulants?
Adderall, vyvanse,
What is the one 2nd line amphetamine based stimulants?
Dexedrine
What are the first line methylphenidate based psychostimulants?
Biphentin, concerta, foquest, quillivant
What are the second line methylphenidate based psychostimulants?
Ritalin SR
Methylphenidate SA
What is a special consideration about ritalin SR
Ritalin SR has an affect of 8 hours BUT its therapeutic effect does not qualify for it to be a long acting agent.
What are the 2nd line selective norepinephrine reuptake inhibitors
atomoxetine
What are the 2nd line Alpha 2A adrenergic receptor agonist
Intuniv XR
What is the one major contraindications to all ADHD medications?
known hypersensitivity or allergy to products duh..,.
What are the precautions to taking all ADHD medications?
What is to be monitored during treatment with ALL adhd medications?
What are the true contraindications to psychostimulants? (7)
What are the precautions with taking psychostimulants?
What is to be monitored during treatment with psychostimulants?
What are the specific contraindications to atomoxetine? (8)
What should be precautioned with atomoxetine (3)
