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ADHD Flashcards

1
Q

ADHD is a neurodevelopmental disorder defined by what things? (3)

A
  1. Impairing levels of inattention
  2. Disorganization
  3. And/or hyperactivity-impulsivity
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2
Q

What does inattention and disorganization entail in ADHD pt?

A

Inability to stay on task, seeming not to listen, and losing materials, at levels that are inconsistent with age or devleopmental level

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3
Q

What does hyperactivity-impulsivity entail in ADHD pt?

A

Overactivity, fidgeting, inability to stay seated, intruding into other people’s activities, and inability to wait - symptoms that are excessive for age or developmental level

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4
Q

True or False? There is no biological marker or imaging study that is diagnostic for ADHD?

A

True - it is a clinical diagnosis

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5
Q

What is an essential feature to diagnose ADHD?

A

Persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development

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6
Q

Inattention and hyperactivity-impulsivity requires how many symptoms and for how long in order to be diagnosed?

A

Six or more symptoms that have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities

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7
Q

What are 2 key DSM criteria for the diagnosis of ADHD?

A
  1. Present prior to the age of 12
  2. Present in 2 or more settings
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8
Q

Boys vs Girls - which is ADHD more diagnosed in?

A

Boys

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9
Q

What are some risk factors for developing ADHD? (9)

A
  1. Low birth weight/prematurity
  2. Exposure to smoking during pregnancy
  3. Family history of ADHD
  4. Perinatal stress
  5. Fetal alcohol syndrome
  6. Lead poisoning
  7. Traumatic brain injury
  8. Severe early oxygenation deprivation
  9. Adverse parent-child relationships
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10
Q

In terms of pathophysiology of ADHD, what are some potential links to anatomical structures? (2)

A
  1. Delay and rate of cortical thickening contributes to difficulty prioritizing tasks
  2. Lack of connectivity between prefrontal cortex is associated with lapses in attention and poor impulse control
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11
Q

In terms of pathophysiology of ADHD, what are some dopamine and norepinephrine abnormalities? (2)

A
  1. 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
  2. NE dysfunction leads to inability to modulate attention, arousal, and mood
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12
Q

What are some signs and symptoms of ADHD in infancy? (4)

A
  1. Difficulty being soothed because irritability, fidgeting, crying and/or colic
  2. Feeding problems including poor sucking, crying during feedings
  3. Short periods of sleep or very little sleep
  4. When crawling in constant motion
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13
Q

What are some signs and symptoms of ADHD in school age? (5)

A
  1. Constantly “on the go”, unable to stay seated or play quietly
  2. Easily distracted, trouble completing tasks
  3. Impulsive, unable to wait turn, may blurt out answers, needs instant gratification
  4. May appear accident prone due to hyperactivity and impulsivity
  5. Disorganized, forgetting or losing homework
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14
Q

What are some signs and symptoms of ADHD in adolescence? (2)

A
  1. Dominant features include disorganization, forgetfulness, inattention, overreaction
  2. Reckless driving and risky behaviour may occur
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15
Q

What are some signs and symptoms of ADHD in adulthood? (3)

A
  1. Hyperactive symptoms include inability to sit through class/work meetings, excessive talking, needs to get to places quickly
  2. Impulsive symptoms include frequent job changes, low frustration tolerance, unstable interpersonal relationships
  3. Inattentive symptoms include poor time management, poor motivation and concentration, forgetfulness, excessive mistakes
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16
Q

What are 2 important tools that are recommended by CADDRA guidelines for initial information gathering for children/adolescents suspected of ADHD?

A
  1. SNAP-IV 26 questionnaire
  2. CADDRA Teacher Assessment Form
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17
Q

In ADHD, approximately __% diagnosed as children continue to have symptoms that persist into adulthood, resulting in _% of the adult population

A

60%, 4%

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18
Q

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

A
  1. Delay in motor and language development
  2. Difficult temperament
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19
Q

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

A
  1. Usually when initial symptoms start
  2. Hyperactive/impulsive symptoms dominate with tendency for intense temper tantrums
  3. Symptoms are less stable and vary between settings
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20
Q

What is the clinical course of ADHD in school age? (5)

A
  1. When initial diagnosis usually occurs
  2. Boys present with hyperactivity/impulsive symptoms that are more noticeable
  3. Girls present with more inattentive symptoms
  4. Hyperactive/impulsive symptoms persist whereas inattentive symptoms develop later
  5. Oppositional and socially aggressive behaviours begin to emerge
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21
Q

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

A
  1. Hyperactive symptoms begin to decline, impulsive and inattentive symptoms persist
  2. Inattentive symptoms may be more prominent
  3. Oppositional and socially aggressive behaviours continue to develop
  4. Substance use disorders may emerge
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22
Q

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

A
  1. More prevalent in males than females (1.6:1)
  2. Inattentive symptoms are most common
  3. Hyperactive/impulsive symptoms associated with higher bipolar/psychosis
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23
Q

What are some comorbidities seen with ADHD? (11 dont need to memorize all, just keep them in mind)

A
  1. Conduct or behavioural problems (52%)
  2. Anxiety (33%)
  3. Major depressive disorder
  4. OCD (1-3%)
  5. Depression (17%)
  6. Oppositional defiant disorder (25-50%)
  7. Tourette’s disorder (1%)
  8. Autism (14%)
  9. Epilepsy is 2-3x more likely
  10. Substance use disorders are 2.5x more likely
    - Alcohol use disorder 2x as common
    - Cocaine use disorder 2x as common
    - Cannabis use disorder 2x as common
    - Nicotine dependence 1.5x as common
  11. Learning disorder 33%
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24
Q

What are some consequences of untreated ADHD? (3)

A
  1. Decreased social, educational, vocational, and self-care functioning
  2. Increased rates of accidental injury
  3. Increased time and energy to cope with ADHD related challenges
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25
Q

What are the goals of therapy for ADHD? (6)

A
  1. Eliminate or significantly decrease the core ADHD symptoms
  2. Improve behavioural, academic, and/or occupational performance
  3. Improve self-esteem
  4. Improve social functioning
  5. Minimize adverse drug effects
  6. Improve quality of life
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26
Q

When might behavioural therapies be the initital treatment of ADHD?

A

If symptoms are mild, diagnosis is unclear, or medication is not preferred by parents

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27
Q

The most effective treatment of ADHD is a combination of…?

A

Behavioural therapies + medication

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28
Q

What are the CADDRA tiers of holistic ADHD care? (5)

A
  1. Adequate education of parents/caregivers and their families
  2. Behavioural and/or occupational interventions
  3. Psychological treatment
  4. Educational accommodation
  5. Medical management
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29
Q

What is behavioural parent training?

A

Behaviour modification principles for parents to implememnt at home to improve compliance with parent’s commands (ex. parent child interaction therapy)

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30
Q

What is behavioural classroom management?

A

Provides principles for teacher to implement in order to improve attention, work, productivity, compliance to classroom rules

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31
Q

What are behavioural peer interventions?

A

Focus on peer interactions and relationships

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32
Q

CBT in ADHD, yay or nay?

A

Reduces core ADHD symptoms in short term, but additional long-term studies needed. Tailors treatment to individual’s behaviours.
Probably a yay

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33
Q

For ADHD, meds should target ________ ____ _____ ___________

A

symptoms that cause impairment

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34
Q

Atomoxetine vs. Concerta (methylphenidate) - What is the bottom line of the first landmark ADHD study?

A

In treatment of ADHD without comorbidities (besides ODD), Concerta is 1st line option. ATX is second line for Concerta non-responders. However, if patient’s family is hesitant to start a stimulant, ATX is an option although not as effective as MPH. Also, if pt doesn’t respond to MPH, then ATX could be an option

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35
Q

In the 2nd landmark ADHD study, what were the results when it came to pharm treatment and behavioural treatment for treating ADHD? (3)

A

At end of 14 months:
1. Combined behavioural + pharm treatment = pharm alone for core ADHD symptoms
2. Pharm treatment > behavioral treatment for core ADHD treatment
3. Combined behavioral + pharm treatment > pharm alone or behavioral alone for reducing oppostional behaviors/anxiety and improving social interactions/self-esteem

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36
Q

What are the 2 classes of ADHD medications?

A
  1. Stimulants
  2. Non-stimulants
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37
Q

What are the 2 stimulant product types for ADHD treatment?

A
  1. Methylphenidate products
  2. Amphetamine products
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38
Q

What are the non-stimulant meds for ADHD treatment? (5)

A
  1. Atomoxetine
  2. Guanfacine
  3. Clonidine
  4. Bupropion
  5. Others
39
Q

What is the MOA of methylphenidate? (4)

A
  1. Inhibits the presynaptic reuptake of DA and NE by specifically blocking transport proteins
  2. DA appears to have larger role than NE
  3. Leads to increased sympathomimetic activity in CNS
  4. Limited peripheral activity
40
Q

What is the MOA of amphetamine in ADHD? (4)

A
  1. Increase the release of DA and NE into the synapses from presynaptic nerve terminal
  2. Enhance release of NE in periphery from adrenergic nerve terminals
  3. May stimulate the release of serotonin and act as a serotonin agonist (higher doses)
  4. Inhibit the reuptake of monoamines in extraneuronal space
41
Q

Atomoxetine is very structurally similar to what medication?

A

Fluoxetine

42
Q

What is the MOA of atomoxetine?

A

Inhibits the presynaptic reuptake of NE in the CNS

43
Q

What is the MOA of guanfacine and clonidine? (3)

A
  1. Alpha-2 adrenergic receptor agonists
  2. Guanfacine is more selective for the alpha2A receptor than clonidine
    - Binds to postsynaptic alpha2A receptors in the PFC –> improves delay related firing of PFC neurons
    - Leads to improvement in underlying working memory and behavioural functions
  3. Peripherally block sympathetic nerve impulses = decreased vasomotor tone (blood pressure) and heart rate
44
Q

What is 1st line pharmacotherapy for ADHD?

A

Long-acting stimulants
- Adderall XR
- Vyvanse
- Biphentin
- Concerta
- Foquest
- Quillivant

45
Q

How quick is the response to long-acting stimulants? How long is an adequate trial?

A

Some response seen in 1st week for some, adequate trial 3-4 weeks

46
Q

True or False? Methylphenidate and amphetamines are equally efficacious in ADHD treatment?

A

True - no method to predict which stimulant class pt will respond to though

47
Q

If treatment failure occurs with one stimulant class, what should be done?

A

The other class should be tried before moving to a non-stimulant

48
Q

What are some positives of using sustained-release/long-acting stimulants for ADHD treatment? (2)

A
  1. Maintain privacy for pts and family in context of school, work, and social situations
  2. Compared to IR formulations, LA ones may diminish diversion and rebound, are associated with better tolerability
49
Q

What is 2nd line pharmacotherapy for ADHD? (3)

A
  1. Atomoxetine
  2. Guanfacine XR
  3. Short/intermediate acting psychostimulants
    - Dextroamphetamine
    - Dextroamphetamine Spansules
    - Methylphenidate
    - Methylphenidate SR
50
Q

How long is the onset for non-stimulants in ADHD?

A

Onset 2 weeks, max effect seen at 6-8 weeks (slower than stimulants)

51
Q

When might atomoxetine or gaunfacine be used first line? (4)

A

If stimulants are;
1. Contraindicated
2. Intolerable adverse effects develop
3. Comorbid active substance use
4. Severe anxiety or tic disorders present, parents hesitant to use a stimulant

52
Q

What would be done if a patient is on either atomoxetine or guanfacine and there is only a partial response?

A

Combine with behavioural therapy or stimulant (off-label)

53
Q

When might short/intermediate acting psychostimulants be used for ADHD? (3)

A
  1. Used to augment long-acting formulations early or late in day or early evening
  2. Dextroamphetamine products are used to augment long-acting amphetamine products and lisdexamfetamine
  3. Methylphenidate products are used to augment methylphenidate extended and controlled release products
54
Q

What are the 3rd line agents for ADHD treatment? (6)

A
  1. Bupropion
  2. Clonidine
  3. Imipramine
  4. Modafinil
  5. Atypical antipsychotics are used for comorbidities commonly seen with ADHD
  6. Exceeding recommended max doses by CADDRA is 3rd line option that may be considered after regular dosages of different options have been tried
55
Q

What makes a 3rd line med a 3rd line med in ADHD treatment? (2)

A
  1. Agents whose use is off-label, have higher risks, more adverse drug effects, and/or lower efficacy profile
  2. Reserved for treatment resistant cases and may require specialized care
56
Q

In terms of first line options what do we have available in Saskatchewan for ADHD treatment? (3)

A
  1. Concerta the easiest one
  2. Vyvanse is EDS
  3. Biphentin is EDS
57
Q

In terms of second line options, what do we have available in Saskatchewan for ADHD treatment? (3)

A
  1. Dexedrine
  2. Ritalin SR
  3. Atomoxetine is EDS
58
Q

When switching from a brand to generic methylphenidate product, what should be done according to CADDRA (practice point box slide)

A

The decision to switch to a generic formulation is an individual-based decision and the CADDRA Guidelines Committee strongly advocates that the patient/family be advised of the switch, told to check for clinical changes in efficacy or tolerability and report any changes to their pharmacist and doctor

59
Q

CADDRA med selection - what are some patient-related factors to think about when choosing an ADHD med? (4)

A
  1. Age and individual variation
  2. Duration of effect required by timing of symptoms
  3. Concurrent psychiatric and medical issues
  4. Physician, family, and patient attitudes
60
Q

CADDRA med selection - what are some medication-related factors to think about when choosing an ADHD med? (5)

A
  1. Active ingredient/mode of action/drug interactions
  2. Delivery system/onset of action/duration of action
  3. Available doses
  4. Canadian clinical indications
  5. Affordability, accessibility, and reimbursement (public/private)
61
Q

CADDRA med selection - what are some special considerations to think about when choosing an ADHD med? (3)

A
  1. Combining medication for adjunct effects
  2. Potential of abuse, misuse, and diversion
  3. Generic formulations
62
Q

For all ADHD meds, what are some precautions (pre-existing conditions in pts) to be aware of when selecting a med? (4)

A
  1. Cardiac disease
  2. Bipolar disorder
  3. Psychosis
  4. Pregnancy and lactation
63
Q

For all ADHD meds, what should be monitored during treatment? (6)

A
  1. Height and weight in children
  2. New mood, anxiety, substance use disorder, psychotic or manic symptoms
  3. Suicidal behaviour or ideation
  4. Aggressive behaviour (new or worsening)
  5. Sleep, appetite
  6. Irritability/mood swings
64
Q

What are some contraindications to using psychostimulants? (7)

A
  1. Treatment with MAOI and for up to 14 days after discontinuation
  2. Glaucoma (narrow angle)
  3. Untreated hyperthyroidism
  4. Moderate to severe HTN
  5. Pheochromocytoma
  6. Symptomatic CVD
  7. History of mania or psychosis
65
Q

What are some precautions to using psychostimulants? (6)

A
  1. History of substance abuse
  2. Anxiety
  3. Renal impairment
  4. Tic disorders
  5. Epilepsy
  6. Peripheral vasculopathy including Raynaud’s Phenomenon
66
Q

What should be monitored when pt is on psychostimulant? (4)

A
  1. BP, HR (may increase)
  2. Priapism
  3. Growth retardation
  4. Peripheral vasculopathy including Raynaud’s Phenomenon
67
Q

What are some contraindications to using atomoxetine? (8)

A
  1. Treatment with MAOI and for up to 14 days after discontinuation
  2. Narrow angle glaucoma
  3. Uncontrolled hyperthyroidism
  4. Pheochromocytoma
  5. Moderate to severe HTN
  6. Symptomatic CVD
  7. Severe CV disorders*
  8. Advanced arteriosclerosis*
    * = specific to atomoxetine, rest are the same as psychostims
68
Q

What are precautions to using atomoxetine? (3)

A
  1. Asthma
  2. CYP2D6 poor metabolizers
  3. Peripheral vasculopathy including Raynaud’s Phenomenon
69
Q

What should be monitored when a pt is using atomoxetine? (4)

A
  1. Priapism and urinary retention
  2. Signs/symptoms of liver injury
  3. Growth retardation
  4. Peripheral vasculopathy including Raynaud’s Phenomenon
70
Q

What is the contraindication to using alpha-2 agonists (guanfacine, clonidine)?

A

Inability for parents or pts to ensure regular daily dosage (due to risk of rebound HTN when stopped abruptly)

71
Q

What are 2 precautions in using alpha-2 agonists (guanfacine, clonidine)?

A
  1. Hepatic impairment
  2. Kidney impairment
72
Q

What should be monitored when a pt is using an alpha-2 agonist (guanfacine, clonidine)? (5)

A
  1. Somnolence and sedation
  2. BP, risk of hypotension
  3. Bradycardia, syncope
  4. Elevated BP and HR upon abrupt discontinuation
  5. QTc interval (to be monitored if underlying conditions or other medication increase the risk of prolonged QTc interval)
73
Q

There are a lot of DI’s associated with amphetamines. What are the important classes you should know? (5)

A
  1. MAOIs
  2. SSRI/SNRI
  3. TCAs
  4. Antihypertensive agents
  5. Antipsychotics
74
Q

There are a lot of DI’s associated with methylphenidate products. What are the important classes to know? (6)

A
  1. Anticoagulant (warfarin)
  2. Anticonvulsants
  3. MAOI
  4. SSRI/SNRI
  5. TCAs
  6. Antihypertensive agents
75
Q

Psychostimulants vs. Atomoxetine vs. Alpha-2 Agonist (Guanfacine XR). Which ones have the following side effect: BP and HR decrease

A

Psychostimulants - no
Atomoxetine - no
Alpha-2 - yes

76
Q

Psychostimulants vs. Atomoxetine vs. Alpha-2 Agonist (Guanfacine XR). Which ones have the following side effect: BP and HR increase

A

Psychostimulants - yes
Atomoxetine - yes
Alpha-2 - when stopped abruptly

77
Q

Psychostimulants vs. Atomoxetine vs. Alpha-2 Agonist (Guanfacine XR). Which ones have the following side effect: appetite suppression

A

Psychostimulants - yes
Atomoxetine - yes
Alpha-2 - low incidence

78
Q

Psychostimulants vs. Atomoxetine vs. Alpha-2 Agonist (Guanfacine XR). Which ones have the following side effect: constipation/diarrhea

A

Psychostimulants - yes
Atomoxetine - yes
Alpha-2 - yes

79
Q

Psychostimulants vs. Atomoxetine vs. Alpha-2 Agonist (Guanfacine XR). Which ones have the following side effect: dry mouth

A

Psychostimulants - yes
Atomoxetine - yes
Alpha-2 - yes

80
Q

Psychostimulants vs. Atomoxetine vs. Alpha-2 Agonist (Guanfacine XR). Which ones have the following side effect: nausea/vomiting

A

Psychostimulants - yes
Atomoxetine - yes
Alpha-2 - yes

81
Q

Psychostimulants vs. Atomoxetine vs. Alpha-2 Agonist (Guanfacine XR). Which ones have the following side effect: GI upset

A

Psychostimulants - yes
Atomoxetine - yes
Alpha-2 - abdominal upper pain reported

82
Q

Psychostimulants vs. Atomoxetine vs. Alpha-2 Agonist (Guanfacine XR). Which ones have the following side effect: anxiety

A

Psychostimulants - yes
Atomoxetine - yes
Alpha-2 - low incidence

83
Q

Psychostimulants vs. Atomoxetine vs. Alpha-2 Agonist (Guanfacine XR). Which ones have the following side effect: dizziness

A

Psychostimulants - yes
Atomoxetine - no
Alpha-2 - yes

84
Q

Psychostimulants vs. Atomoxetine vs. Alpha-2 Agonist (Guanfacine XR). Which ones have the following side effect: dysphoria/irritability

A

Psychostimulants - yes
Atomoxetine - yes
Alpha-2 - uncommon

85
Q

Psychostimulants vs. Atomoxetine vs. Alpha-2 Agonist (Guanfacine XR). Which ones have the following side effect: headache

A

Psychostimulants - yes
Atomoxetine - yes
Alpha-2 - yes

86
Q

Psychostimulants vs. Atomoxetine vs. Alpha-2 Agonist (Guanfacine XR). Which ones have the following side effect: initial insomnia

A

Psychostimulants - yes
Atomoxetine - yes
Alpha-2 - low incidence

87
Q

Psychostimulants vs. Atomoxetine vs. Alpha-2 Agonist (Guanfacine XR). Which ones have the following side effect: somnolence

A

Psychostimulants - no
Atomoxetine - yes
Alpha-2 - yes

88
Q

Psychostimulants vs. Atomoxetine vs. Alpha-2 Agonist (Guanfacine XR). Which ones have the following side effect: rebound effect

A

Psychostimulants - yes
Atomoxetine - no
Alpha-2 - no

89
Q

Psychostimulants vs. Atomoxetine vs. Alpha-2 Agonist (Guanfacine XR). Which ones have the following side effect: tics

A

Psychostimulants - yes
Atomoxetine - uncommon
Alpha-2 - no

90
Q

Psychostimulants vs. Atomoxetine vs. Alpha-2 Agonist (Guanfacine XR). Which ones have the following side effect: decrease in weight

A

Psychostimulants - yes
Atomoxetine - yes
Alpha-2 - no

91
Q

Psychostimulants vs. Atomoxetine vs. Alpha-2 Agonist (Guanfacine XR). Which ones have the following side effect: sexual dysfunction

A

Psychostimulants - uncommon
Atomoxetine - yes
Alpha-2 - no

92
Q

Psychostimulants vs. Atomoxetine vs. Alpha-2 Agonist (Guanfacine XR). Which ones have the following side effect: skin reactions

A

Psychostimulants - yes
Atomoxetine - yes
Alpha-2 - low incidence

93
Q

Name the amphetamine based psychostimulants (3)

A
  1. Adderall XR
  2. Vyvanse (lisdexamfetamine)
  3. Dexedrine
94
Q

Name the methylphenidate based psychostimulants (6)

A
  1. Biphentin
  2. Concerta
  3. Foquest
  4. Quillivant ER
  5. Methylphenidate short-acting
  6. Ritalin SR

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